Nokea
Priority Decision: Upon admission of a patient to the PACU, the nurse's priority assessment is
- A. vital signs.
- B. surgical site.
- C. respiratory adequacy.
- D. level of consciousness.
Correct Answer: C
Rationale: Respiratory adequacy is critical immediately postoperatively to ensure oxygenation and ventilation.
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A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I can sleep on my side as long as I use a pillow between my legs.
- C. I will avoid bending at the waist to pick things up.
- D. I can bend down to tie my shoes after 2 weeks.
Correct Answer: D
Rationale: The correct answer is D because bending down to tie shoes after only 2 weeks post total hip replacement can put strain on the hip joint and increase the risk of dislocation. The client should avoid bending past 90 degrees to protect the new hip joint. Choices A, B, and C are all correct statements as they promote hip joint protection and reduce the risk of complications.
During an acute asthma attack in a client with asthma, what medication should the nurse administer first?
- A. Oral corticosteroids
- B. Short-acting beta agonist
- C. Leukotriene receptor antagonist
- D. Long-acting beta agonist
Correct Answer: B
Rationale: The correct answer is B: Short-acting beta agonist. During an acute asthma attack, the priority is to quickly relieve bronchoconstriction and improve airflow. Short-acting beta agonists like albuterol are the first-line medications for acute asthma exacerbations as they act rapidly to relax smooth muscles in the airways, providing immediate relief of symptoms. Oral corticosteroids (A) are important for long-term management but do not provide immediate relief. Leukotriene receptor antagonists (C) and long-acting beta agonists (D) are not appropriate for acute asthma attacks as they have slower onset of action and are used for maintenance therapy.
The nurse is caring for a client with trigeminal neuralgia. To assist the client with nutrition needs, the nurse should:
- A. Offer small meals of high calorie soft food.
- B. Assist the client to sit in a chair for meals.
- C. Provide additional servings of fruits and raw vegetables.
- D. Encourage the client to eat fish, liver and chicken.
Correct Answer: A
Rationale: Soft foods minimize facial muscle movement, reducing pain.
Lack of adequate nutrition in older adults may lead to:
- A. Delayed wound healing
- B. Shorter hospital stays
- C. Improved immune status
- D. Decreased mortality rates
Correct Answer: A
Rationale: Poor nutrition weakens tissues and impairs the body's ability to repair itself, resulting in delayed wound healing and increased susceptibility to infections.
A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?
- A. Assess the client's lung sounds.
- B. Call the Rapid Response Team.
- C. Have the client sit upright.
- D. Listen to the client's lung sounds.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's lung sounds. This is important because after a myocardial infarction, there is a risk of pulmonary edema, which can present as crackles or wheezes in the lungs. By assessing the lung sounds, the healthcare provider can identify any signs of respiratory distress and promptly intervene if necessary.
Choice B is incorrect because calling the Rapid Response Team is not warranted based solely on abnormal heart sounds. Choice C is incorrect as having the client sit upright is not directly related to addressing abnormal heart sounds. Choice D is also incorrect as it focuses solely on assessing lung sounds without considering the potential implications of the abnormal heart sounds.