Nokea
The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)?
- A. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain.
- B. The six-(6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication.
- C. The 18-year-old client who had a Caldwell-Luc procedure three (3) days ago and has purulent drainage on the drip pad.
- D. The 45-year-old client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.
Correct Answer: C
Rationale: Purulent drainage post-Caldwell-Luc (C) suggests infection, requiring experienced assessment. Antral irrigation (A), tonsillectomy refusal (B), and antibiotics (D) are less complex.
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The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective?
- A. A decrease in the white blood cells in the sputum.
- B. The client's symptoms are improving.
- C. No change in the chest X-ray.
- D. The skin test is now negative.
Correct Answer: B
Rationale: Improved symptoms (B) after six weeks of TB treatment (e.g., reduced cough, fever) indicate medication efficacy. WBCs in sputum (A) are not a standard measure. Chest X-ray changes (C) lag behind clinical improvement. The skin test (D) remains positive post-exposure, regardless of treatment.
The client has had a total laryngectomy. Which referral is specific for this surgery?
- A. CanSurmount.
- B. Dialogue.
- C. Lost Chord Club.
- D. SmokEnders.
Correct Answer: C
Rationale: Lost Chord Club (C) supports laryngectomy patients with communication and adjustment. CanSurmount (A), Dialogue (B), and SmokEnders (D) are for cancer, CLL, and smoking cessation.
How long after administering a tuberculin skin test should the nurse inspect the client's injection site?
- A. 1 week
- B. 1 day
- C. 2 to 3 days
- D. 4 to 5 days
Correct Answer: C
Rationale: The tuberculin skin test reaction is typically read 48 to 72 hours (2 to 3 days) after administration to assess for induration.
Which nursing measure is most helpful in reducing the client's anxiety during an asthma attack?
- A. Close the door to the examination room.
- B. Remain within the client's view.
- C. Pull the bedside privacy curtain.
- D. Notify the client when the respiratory therapist arrives.
Correct Answer: B
Rationale: Remaining within the client's view provides reassurance and reduces anxiety by ensuring the client feels supported during an asthma attack.
A patient taking Isoniazid (INH) should be monitored for what deficiency?
- A. Vitamin C
- B. Calcium
- C. Vitamin B6
- D. Potassium
Correct Answer: C
Rationale: This medication can lead to low Vitamin B6 levels. Most patients will take a supplement of B6 while taking this medication.