Nokea
On the first encounter with the patient, the nurse will complete a general survey. Which features are included (select all that apply)?
- A. Mental state and behavior
- B. Lung sounds and bowel tones
- C. Body temperature and pulses
- D. Speech and body movements
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client is having a left pneumonectomy. In planning this client's postoperative care, nursing interventions for a postoperative left pneumonectomy would include:
- A. monitoring the chest tubes.
- B. positioning the client on the right side.
- C. positioning the client in the semi-Fowler's position with a pillow under the shoulder and back.
- D. monitoring the right lung for an increase in rales.
Correct Answer: D
Rationale: Chest tubes are not usually necessary in a pneumonectomy, because there is no lung to re-expand on the operative side. The pneumonectomy client should be positioned on the back or operated side, because the sutured bronchial stump may open, which would allow fluid to drain into the unoperated side and drown the client. The client should not have a pillow under the shoulder and back, because of the subscapular incision. Rales are commonly heard over the base of the remaining lung. An increase could indicate circulatory overload. Rales should be closely monitored.
What is the initial management for a foreign body in the eye?
- A. Irrigation
- B. Surgical removal
- C. Topical antibiotics
- D. Observation
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How does client and family care differ for a client with an acute terminal illness versus a chronic terminal illness?
- A. Acute terminal illness requires immediate interventions,while chronic terminal illness focuses on long-term symptom management.
- B. Acute terminal illness involves less family involvement,while chronic terminal illness requires extensive support.
- C. No difference exists.
- D. Care depends solely on the client’s preferences.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which nursing intervention can help a client avoid dealing simultaneously with multiple stimuli?
- A. Reducing activity
- B. Touching the client as often as possible
- C. Increasing bright lights
- D. Taking a position as close to the client as possible
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The patient is complaining of insomnia. Which bedtime snack would be the best option for this patient?
- A. Hershey’s bar
- B. 8 oz hot chocolate
- C. 8 oz Dannon coffee yogurt
- D. 1 cup Ben & Jerry’s nonfat coffee fudge frozen yogurt
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.