Nokea
In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that:
- A. The client will remain in the ICU for 5 days.
- B. The client will sleep most of the time while in the ICU.
- C. Noise and activity within the ICU are minimal.
- D. The client will receive medication to relieve pain.
Correct Answer: D
Rationale: Pain management is a priority post-open heart surgery, and clients receive medications to ensure comfort in the ICU.
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A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes diaphoretic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for:
- A. An air embolus.
- B. A pneumothorax.
- C. A pulmonary embolus.
- D. A myocardial infarction.
Correct Answer: B
Rationale: Absent breath sounds, chest pain, and tachycardia post-catheter insertion suggest a pneumothorax, a known complication of subclavian catheter placement, requiring urgent assessment.
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
- A. Anxiety related to the presence of a urinary diversion.
- B. Deficient knowledge about how to care for the urinary diversion.
- C. Low self-esteem related to feelings of worthlessness.
- D. Unstuffed body image related to creation of a urinary diversion.
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
Following a gastrectomy, the nurse should position the client in which of the following positions?
- A. Prone.
- B. Supine.
- C. Right or left Sims.
- D. Fowler's.
Correct Answer: D
Rationale: Fowler's position (semi-upright) promotes lung expansion, reduces aspiration risk, and aids drainage post-gastrectomy. The other positions are less optimal for postoperative recovery.
Which of the following guidelines reflects the current American Cancer Society recommendations for screening for colon cancer in individuals who are not at high risk?
- A. Annual digital rectal examination should begin at age 40.
- B. Annual fecal testing for occult blood should begin at age 50.
- C. Individuals should obtain a baseline barium enema at age 40.
- D. Individuals should obtain a baseline colonoscopy at age 45.
Correct Answer: B
Rationale: Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they recommend the nurse to the need for such diagnostic testing, or are considered to be at high risk. CN: Health promotion and maintenance; CL: Apply
The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing diagnoses should receive further validation?
- A. Impaired mobility related to spasticity and fatigue.
- B. Risk for falls related to muscle weakness and sensory loss.
- C. Risk for seizures related to muscle tremors and loss of myelin.
- D. Impaired skin integrity related bowel and bladder incontinence.
Correct Answer: C
Rationale: Seizures are not a common manifestation of MS, as tremors and myelin loss do not directly cause seizures. The other diagnoses are valid, as MS commonly causes mobility issues, fall risks, and skin integrity concerns.