Nokea
Sixty-five-year-old Dominic is being transferred into the postanesthesia care unit (PACU) from the OR. Once there, initial assessment will focus on
- A. Airway, breathing, circulation, and wound site.
- B. Intake, output, and intravenous access.
- C. Abdominal sounds, oxygen level, and level of consciousness.
- D. Pulse oximetry, pupil responses, and deep tendon reflexes.
Correct Answer: A
Rationale: ABCs are prioritized in the immediate postoperative period.
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Respiratory disease could best be prevented by avoiding
- A. Coal dust
- B. Spray cans
- C. Carbon monoxide emissions
- D. Cigarette smoking
Correct Answer: D
Rationale: Smoking cessation significantly reduces the risk of respiratory diseases.
A client with chronic obstructive pulmonary disease (COPD tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
- A. Maintaining a semi-Fowler's position as often as possible
- B. Administering oxygen via nasal cannula at 2 L/min
- C. Helping the client select a low-salt diet
- D. Encouraging the client to drink 2 to 3 L of water daily
Correct Answer: D
Rationale: The correct answer is D: Encouraging the client to drink 2 to 3 L of water daily. Increased fluid intake helps to thin out bronchial secretions, making them easier to cough up. Step-by-step rationale:
1. Increased water intake promotes hydration, which thins mucus in the airways.
2. Thinner mucus is easier to expectorate, aiding in clearing airway congestion.
3. Adequate hydration also helps to prevent dehydration, which can further thicken secretions.
Summary:
A: Maintaining a semi-Fowler's position may help with breathing comfort but does not directly address the issue of thick secretions.
B: Administering oxygen is important for COPD patients but does not specifically target bronchial secretions.
C: Selecting a low-salt diet is beneficial for managing fluid retention but does not directly address the issue of tenacious bronchial secretions.
Why might a client receive a central venous catheter?
- A. Client is receiving 0.9 normal saline
- B. Client is receiving total parenteral nutrition (TPN)
- C. Client is receiving short-term IV therapy
- D. Client has had one infiltrated IV
Correct Answer: B
Rationale: The correct answer is B because TPN requires a central venous catheter due to the high osmolarity of the solution.
Which category of complementary and alternative medicine involves healing theory and practice that evolved from other cultures?
- A. Energy medicine
- B. Whole medical systems
- C. Manipulative and body-based therapies
- D. Biologically based practices
Correct Answer: B
Rationale: Whole medical systems, such as Ayurveda and Traditional Chinese Medicine, incorporate theories and practices developed in other cultures.
Which task is most appropriate to delegate to an LPN /LVN?
- A. Talk to a community group about water safety issues
- B. Stabilize the cervical spine for an unconscious drowning victim
- C. Remove wet clothing and cover the victim with a warm blanket
- D. Monitor an asymptomatic near-drowning victim
Correct Answer: C
Rationale: Removing wet clothing and covering the victim with a warm blanket is a straightforward task suitable for an LPN/LVN.