Nokea
A client is diagnosed with lung cancer and undergoes a pneumonectomy.
In the immediate postoperative period, which of the following nursing assessments is MOST important?
- A. Presence of breath sounds bilaterally.
- B. Position of the trachea in the sternal notch.
- C. Amount and consistency of sputum.
- D. Increase in the pulse pressure.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a pneumonectomy. (1) on the surgical side, breath sounds will be absent (2) correct-position of the trachea should be evaluated; with a tracheal shift, an increase in pressure could occur on the operative side and could cause pressure against the mediastinal area (3) important to observe but not as high a priority (4) does not relate to the situation
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The nurse is working on a plan to assist an abused client back into the work situation. Which will likely be most helpful in decreasing the trauma for the client?
- A. Support from significant others
- B. Support from a counselor
- C. Support from friends
- D. Support from coworkers
Correct Answer: A
Rationale: Support from significant others provides emotional stability, most effective in reducing trauma for an abused client re-entering work.
The nurse is teaching a client with a new diagnosis of gout about dietary modifications. Which of the following foods should the nurse advise the client to avoid?
- A. Fresh spinach.
- B. Lean chicken breast.
- C. Canned sardines.
- D. Whole-grain pasta.
Correct Answer: C
Rationale: Canned sardines are high in purines, which increase uric acid levels and exacerbate gout. Options A, B, and D are suitable: spinach is low-purine, chicken is lean, and whole-grain pasta is not restricted.
The nurse is caring for a 14-year-old girl admitted with an acute exacerbation of ulcerative colitis.
- A. What is the best nursing intervention for a 14-year-old with an acute exacerbation of ulcerative colitis?
- B. Encourage her mother to room in with her.
- C. Provide information on the hospital school program.
- D. Ask if she would like to have visits from friends.
- E. Involve her in planning her daily schedule.
Correct Answer: D
Rationale: Involving the adolescent in planning her daily schedule promotes autonomy and control, which is developmentally appropriate and therapeutic for managing chronic illness. Rooming in, school programs, and friend visits are supportive but less empowering for self-management.
At 10:00 A.M., the nurse discovers a 75-year-old woman who is hospitalized with congestive heart failure on the floor beside the bed. She has a bruise on her leg, but x-rays reveal no fractures. How should the nurse record the incident in the client's chart?
- A. Client fell out of bed at 10 A.M. Physician notified. Incident report completed.'
- B. Client found on floor beside bed at 10 A.M. Alert and oriented times 3. States she slipped as she was standing up. Bruise (3 inches by 2 inches) on left hip. Denies pain. Dr. examined client. X-rays taken.'
- C. Client fell while getting out of bed. Seems okay. Charge nurse examined client. Doctor notified and incident report filed.'
- D. Found client on floor beside bed. Responds to questions. Red area on left hip. Notified charge nurse and physician.'
Correct Answer: B
Rationale: Accurate documentation includes specific details: time, client status, mechanism of fall, assessment findings (bruise size, orientation), and actions taken (physician notification, x-rays). This option is thorough and objective, unlike the others, which are vague or incomplete.
A client receiving Eskalith (lithium carbonate) has a level of 4.5 mEq/L. The nurse should prepare the client for immediate:
- A. Blood transfusion
- B. Hemodialysis
- C. Renal biopsy
- D. Brain scan
Correct Answer: B
Rationale: A lithium level of 4.5 mEq/L indicates severe toxicity, requiring hemodialysis to rapidly remove lithium from the body.