Nokea
The client is three (3) days post-partial laryngectomy. Which type of nutrition should the nurse offer the client?
- A. Total parenteral nutrition.
- B. Soft, regular diet.
- C. Partial parenteral nutrition.
- D. Clear liquid diet.
Correct Answer: D
Rationale: Clear liquids (D) are safest 3 days post-laryngectomy to prevent aspiration. TPN (A), soft diet (B), and partial PN (C) are premature or unnecessary.
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The client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain and a feeling of impending doom. Which complication should the nurse suspect the client has experienced?
- A. Myocardial infarction.
- B. Pneumonia.
- C. Pulmonary embolus.
- D. Pneumothorax.
Correct Answer: C
Rationale: Sudden chest pain and impending doom in a DVT patient suggest pulmonary embolus (C), where a clot dislodges to the lungs, causing acute respiratory distress. Myocardial infarction (A) presents with cardiac symptoms. Pneumonia (B) has gradual onset. Pneumothorax (D) causes unilateral symptoms.
Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required?
- A. I should contact my health-care provider if my sputum changes color or amount.
- B. I will take my bronchodilator regularly to prevent having bronchospasms.
- C. This metered-dose inhaler gives a precise amount of medication with each dose.
- D. I need to return to the HCP to have my blood drawn with my annual physical.
Correct Answer: D
Rationale: Blood draws (D) are not routine for bronchitis, indicating misunderstanding. Sputum changes (A), bronchodilator use (B), and inhaler accuracy (C) reflect correct understanding.
Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear?
- A. N95 mask
- B. Surgical mask
- C. No special PPE is needed
- D. Face mask with shield
Correct Answer: C
Rationale: Patients with a latent tuberculosis infection are NOT contagious. Therefore, no special PPE is needed for the patient during transport. HOWEVER, if the patient had ACTIVE tuberculosis they would need to wear a surgical mask during transport.
Before suctioning, the nurse attaches a pulse oximeter to the client's finger. Which nursing actions are appropriate at this time? Select all that apply.
- A. Remove the client's fingernail polish.
- B. Place the sensor and receiver opposite to each other on the client's finger.
- C. Connect the cable to the oximeter.
- D. Set the SpO2 alarms between 95% and 100%.
- E. Notify the physician each time an alarm sounds.
- F. Relocate the spring-loaded sensor periodically.
Correct Answer: A, B, C, F
Rationale: Removing nail polish, positioning the sensor correctly, connecting the cable, and relocating the sensor periodically ensure accurate pulse oximetry readings.
A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in precautions and will always wear when providing patient care?
- A. droplet, respirator
- B. airborne, respirator
- C. contact and airborne, surgical mask
- D. droplet, surgical mask
Correct Answer: B
Rationale: Active tuberculosis requires airborne precautions due to its transmission via respiratory droplets. A respirator (e.g., N95) is required for healthcare workers, not a surgical mask, to protect against inhaling the bacteria.