Nokea
In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to:
- A. Avoid overheating during physical activities.
- B. Maintain normal activity with some restrictions.
- C. Be cautious of others with viruses or temperatures.
- D. Maintain routine immunizations.
Correct Answer: D
Rationale: Immunizations protect against infections that can trigger crises.
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A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?
- A. Patency of the intravenous line
- B. Level of pain
- C. Integrity of the dressing
- D. Need for suctioning
Correct Answer: D
Rationale: The correct answer is D: Need for suctioning. After a laryngectomy, maintaining a clear airway is crucial to prevent aspiration and ensure proper oxygenation. Suctioning helps remove secretions and maintain airway patency. Monitoring for signs of respiratory distress is essential.
A: Patency of the intravenous line is important but not the priority over airway management.
B: Level of pain is important but not as critical as ensuring a clear airway.
C: Integrity of the dressing is important for wound healing but does not directly impact airway patency.
A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
- A. Raise the foot of the bed to a 90° angle
- B. Remove the dressing to inspect the wound
- C. Prepare to insert a central line
- D. Administer oxygen via nasal cannula
Correct Answer: D
Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration.
A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation.
B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity.
C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.
Mrs. Williams asks what “presbyopia†means. The best response would be that Mrs. Williams
- A. is 'farsighted' and can see well at a distance, but her near vision is poor
- B. is 'nearsighted' and can see well when objects are close but cannot see well at a distance
- C. has distorted vision which is caused by a curvature in the eye
- D. has difficulty seeing objects that are very close because her lens is less elastic
Correct Answer: D
Rationale: Presbyopia results from decreased elasticity of the eye's lens, impairing the ability to focus on nearby objects, typically occurring with age.
What is the definition of substance abuse?
- A. A compulsive need to experience pleasure
- B. Behavior associated with maintaining an addiction
- C. Absence of a substance will cause withdrawal symptoms
- D. Overuse and dependence on a substance that negatively affects functioning.
Correct Answer: D
Rationale: Substance abuse involves overuse and dependence on a substance leading to negative impacts on one's life, encompassing both physical and social consequences.
What would be useful in helping Mr. Jackson prepare for chest tube insertion?
- A. Explain the etiology of his condition
- B. Ask if he has any questions about the insertion procedure and its purpose
- C. Teach him to splint his chest wall
- D. Reassure him that the procedure is painless
Correct Answer: C
Rationale: Splinting minimizes movement and discomfort during the procedure.