Nokea
Patients returning from the operating room (OR) should be monitored for atelectasis. Why is this important?
- A. Immobility, anesthesia, and lack of deep breathing place the patient at risk for collapsed lung.
- B. All postoperative patients are at risk for infection.
- C. Postoperative patients might have received too much oxygen during surgery.
- D. Postoperative patients do not receive enough oxygen during surgery.
Correct Answer: A
Rationale: Anesthesia and immobility can lead to atelectasis, where parts of the lung collapse.
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Complications of overeating include which of the following?
- A. Hyperlipidemia
- B. Type I diabetes
- C. Sleep disturbances
- D. Rheumatoid arthritis
Correct Answer: A
Rationale: Overeating can lead to elevated cholesterol levels, contributing to hyperlipidemia and cardiovascular risks.
Paralytic ileus may occur as a postoperative complication. Which of the following patients would cause you the greatest concern about the development of paralytic ileus?
- A. Kim, a 27-year-old postlaparoscopic appendectomy.
- B. Joyce, a 39-year-old post–open right hemicolectomy.
- C. Nancy, a 56-year-old postmediastinoscopy.
- D. John, a 47-year-old post–total joint replacement.
Correct Answer: B
Rationale: Open abdominal surgeries increase the risk of paralytic ileus.
The nurse knows that a patient taught sleep hygiene practices needs further instruction when he says
- A. Once I go to bed, I should get up if I am not asleep after 20 minutes.
- B. It’s okay to have my usual two glasses of wine in the evening before bed.
- C. A couple of crackers with cheese and a glass of milk may help to relax before bed.
- D. I should go to the gym earlier in the day so that I’m done at least 6 hours before bedtime.
Correct Answer: B
Rationale: The correct answer is B. Alcohol disrupts sleep architecture, making it counterproductive for sleep hygiene. Getting up after 20 minutes (A) is a recommended practice, and exercising early (D) promotes better sleep.
In doing a nutritional assessment for Mrs. Collins who wants to lose weight, what should the nurse initially do?
- A. Ask her to describe her actual food intake and behaviors influencing eating
- B. Determine who does the cooking and shopping
- C. Determine what she knows about the basic four food groups
- D. Determine biochemical data such as urinalysis and blood chemistries
Correct Answer: A
Rationale: Understanding the patient's current eating habits and behaviors is crucial for tailoring an effective weight loss plan.
A client with diabetes is experiencing symptoms of hypoglycemia. What should the nurse administer first?
- A. 10 units of regular insulin subcutaneously
- B. 50 mL of 50% dextrose solution intravenously
- C. 1 mg of glucagon intramuscularly
- D. 15-20 grams of fast-acting carbohydrate orally
Correct Answer: D
Rationale: The correct answer is D: 15-20 grams of fast-acting carbohydrate orally. In hypoglycemia, the immediate goal is to raise blood glucose levels quickly. Fast-acting carbohydrates like glucose tablets or juice are the most effective and fastest way to raise blood sugar levels. Administering insulin (choice A) would further lower blood sugar levels. Intravenous dextrose (choice B) is appropriate for severe cases but may not be necessary as the first step. Glucagon (choice C) is typically used if the client is unconscious or unable to consume oral carbohydrates.