Mary, who is scheduled for a thoracentesis, asks why there is so much fluid in the pleural space. You respond by saying
- A. Your body is unable to remove fluid, resulting in a buildup of fluid in the pleural space around your lungs.
- B. An error occurred and you were administered too much IV medication.
- C. This is the result of oxygen therapy.
- D. This is a normal side effect of bumetanide, which is medication ordered by your physician.
Correct Answer: A
Rationale: Fluid accumulation in the pleural space can occur due to various conditions like heart failure or infection.
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A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed
occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?
- A. "We can teach you some relaxation techniques to minimize your pain."
- B. "Keep wire cutters with you at all times."
- C. "Use a water pick device to keep your teeth clean."
- D. "Consume a high-protein, liquid diet."
Correct Answer: B
Rationale: The correct answer is B: "Keep wire cutters with you at all times." This is the priority statement because in the event of an emergency, such as airway obstruction or trauma, quick access to wire cutters is crucial to ensure timely removal of the jaw fixation wires. Without immediate access to wire cutters, the client may suffer serious complications.
Incorrect choices:
A: "We can teach you some relaxation techniques to minimize your pain." - While pain management is important, it is not the priority in this situation where the immediate risk is airway compromise.
C: "Use a water pick device to keep your teeth clean." - Oral hygiene is important but not as critical as ensuring access to wire cutters for emergency situations.
D: "Consume a high-protein, liquid diet." - Nutrition is important for healing but is not as time-sensitive as having wire cutters readily available in case of an emergency.
The PACU nurse applies warm blankets to a postoperative patient who is shivering and has a body temperature of 96.0°F (35.6°C). What treatment also may be used to treat the patient?
- A. Oxygen
- B. Vasodilating drugs
- C. Antidysrhythmic drugs
- D. Analgesics or sedatives
Correct Answer: A
Rationale: Shivering increases oxygen demand; providing oxygen supports metabolic needs.
If the patient becomes discouraged during the rehabilitation program, what should the nurse do?
- A. Tell the family that the patient has not adjusted
- B. Stop the rehabilitative program until the patient is more optimistic
- C. Listen to his complaints and continue to encourage him
- D. Ignore his complaints and continue with the rehabilitation efforts
Correct Answer: C
Rationale: Active listening and encouragement help maintain motivation and adherence to the rehabilitation program.
A patient who is being admitted to the surgical unit for a hysterectomy paces the floor, repeatedly saying, 'I just want this over.' What should the nurse do to promote a positive surgical outcome for the patient?
- A. Ask the patient what her specific concerns are about the surgery.
- B. Reassure the patient that the surgery will be over soon and she will be fine.
- C. Redirect the patient's attention to the necessary preoperative preparations.
- D. Tell the patient she should not be so anxious because she is having a common, safe surgery.
Correct Answer: A
Rationale: Understanding the patient's specific concerns allows the nurse to address fears directly, promoting a positive outcome.
Until doctor's orders are received, the most appropriate position for Mr. Jones, admitted with retinal detachment, is lying
- A. flat on his back
- B. on his left side
- C. on his right side
- D. on his abdomen
Correct Answer: B
Rationale: Lying on the affected side (left side) helps reduce movement of the detached retina, minimizing further damage until definitive treatment can be administered.