Nokea
The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.
- A. The family is coming in to visit.
- B. The client has increased secretions requiring frequent suctioning.
- C. The SpO2 and PO2 have decreased.
- D. The client is tachycardic with drop in blood pressure.
- E. The face has increased skin breakdown and edema.
Correct Answer: C,D,E
Rationale: Decreased SpO2/PO2 (C), tachycardia with hypotension (D), and facial skin breakdown/edema (E) indicate complications requiring a return to supine position. Family visits and suctioning needs are manageable in prone position.
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The wife of a terminally ill client asks the nurse, 'Why is my husband having frequent bowel movements if he is not eating?' Which of the following responses by the nurse informs the wife about the client's condition?
- A. I know he is having frequent loose stools and it is distressing for you, but that's just the way it is.
- B. I don't know when the bowels will shut down, but they will eventually.
- C. The pain medication will eventually help to slow the process of bowel function.
- D. The intestines still produce some waste products even when a person is not eating.
Correct Answer: D
Rationale: The intestines continue to produce waste from residual secretions and cellular turnover, even with minimal intake, explaining the frequent bowel movements.
Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and finds the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes that he had 2,000 mL of I.V. fluid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. This would indicate which of the following?
- A. Decreased renal function.
- B. Inadequate pain relief.
- C. Extension of the obstruction.
- D. Inadequate fluid replacement.
Correct Answer: D
Rationale: The low urine output (35 mL in 2 hours) and a 24-hour output (1,200 mL) less than intake (2,000 mL) suggest inadequate fluid replacement, as the body is retaining fluid or losing it through vomiting and NG drainage. Decreased renal function, pain, or obstruction extension are less directly indicated. CN: Physiological adaptation; CL: Analyze
A client in a hospice program has increasing pain. The nurse and client collaborate to schedule analgesics to provide which of the following?
- A. Doses of analgesic when pain is a '5' on a scale of 1-10.
- B. Enough analgesia to keep the client semisomnolent.
- C. An analgesia-free period so that the client can carry out daily hygienic activities.
- D. Around-the-clock routine administration of analgesics for continuous pain relief.
Correct Answer: D
Rationale: Around-the-clock administration of analgesics ensures continuous pain relief, which is critical for hospice patients with persistent pain, preventing pain escalation.
Which position is best for a client with a hemorrhagic stroke?
- A. Flat supine.
- B. Head elevated 30 degrees.
- C. Prone position.
- D. Trendelenburg position.
Correct Answer: B
Rationale: Head elevation at 30 degrees reduces intracranial pressure while maintaining cerebral perfusion in hemorrhagic stroke.
Postoperative nursing management of the client following a radical neck dissection for laryngeal cancer requires:
- A. Complete bed rest minimizing head movement.
- B. Vital signs once a shift.
- C. A. All the nurse should be made to be removed at 48 hours.
- D. Frequent suctioning of the laryngectomy tube.
Correct Answer: D
Rationale: Frequent suctioning of the laryngectomy tube prevents mucus buildup and maintains airway patency. Complete bed rest is unnecessary; early mobility is encouraged. Vital signs should be monitored more frequently than once per shift. The third option is unclear but likely incorrect.