Nokea
The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?
- A. Blood pressure apparatus
- B. IV infusion stand
- C. Call bell
- D. Endotracheal intubation
Correct Answer: A
Rationale: Rationale:
1. A: Blood pressure apparatus is essential to monitor for any signs of bleeding or clot formation after carotid angioplasty.
2. B: IV infusion stand is important but not the priority for immediate postoperative monitoring.
3. C: Call bell is important for the client to call for assistance but not the priority for immediate postoperative care.
4. D: Endotracheal intubation is not necessary after a carotid angioplasty and is not a priority item for bedside care.
Summary: Monitoring blood pressure is crucial for detecting complications post carotid angioplasty. IV stand, call bell, and endotracheal intubation are important but not the priority in this scenario.
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Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse’s analysis are:
- A. Rise in blood pressure and heart rate
- B. Rise in blood pressure and drop in heart rate
- C. Drop in blood pressure and rise in heart rate
- D. none of the above
Correct Answer: C
Rationale: The correct answer is C: Drop in blood pressure and rise in heart rate. After a splenectomy, the client is at risk for orthostatic hypotension due to decreased blood volume. A drop in blood pressure and a compensatory rise in heart rate are common orthostatic changes. This occurs because the body tries to maintain perfusion to vital organs. A rise in blood pressure and heart rate (Choice A) would not align with orthostatic changes. A rise in blood pressure and drop in heart rate (Choice B) is contradictory to the body's compensatory response to maintain perfusion. Therefore, the most supportive vital sign values for abnormal orthostatic changes in this client would be a drop in blood pressure and a rise in heart rate.
A nurse changes a client’s wound dressing according to the protocol outlined by the health care agency. What type of nursing intervention is this?
- A. Independent intervention
- B. Dependent intervention
- C. Interdependent intervention
- D. Collaborative intervention
Correct Answer: C
Rationale: The correct answer is C: Interdependent intervention. This type of nursing intervention involves collaboration with other healthcare professionals to provide holistic care. In this scenario, the nurse is following a protocol set by the health care agency, which likely involves input and guidance from various team members. The nurse's actions require coordination and communication with others to ensure the best outcome for the client.
Choice A (Independent intervention) would involve actions that the nurse can perform autonomously without requiring direction from others. Choice B (Dependent intervention) would require an order or prescription from a healthcare provider for the nurse to carry out. Choice D (Collaborative intervention) involves working together with other healthcare professionals on a specific aspect of care, but in this case, the nurse is primarily following a set protocol without necessarily actively collaborating with others during the task.
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
- A. Wilma places 2 fingers between the tie and neck
- B. The tracheotomy can be pulled slightly away from the neck
- C. James’ neck veins are not engorged
- D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process
Correct Answer: A
Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow.
Incorrect choices:
B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties.
C: James’ neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties.
D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.
In order to educate clients, the nurse should understand that the most common site of cancer for a female is the:
- A. Uterine cervix
- B. Vagina
- C. Uterine body
- D. Fallopian tube
Correct Answer: C
Rationale: The correct answer is C: Uterine body. The rationale is that the most common site of cancer for females is uterine body, specifically endometrial cancer. This is due to the high prevalence of hormonal imbalances and estrogen exposure, which are risk factors for this type of cancer. The other choices, A: Uterine cervix, B: Vagina, and D: Fallopian tube, are less common sites of cancer in females compared to the uterine body. Understanding the prevalence and risk factors associated with each site of cancer is crucial for nurses to educate clients effectively.
An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?
- A. Evaluation of the peripheral venous site
- B. Confirmation that the tube is in the stomach
- C. Assessment of the GI tract, including bowel sounds
- D. Fluid and electrolyte monitoring
Correct Answer: D
Rationale: The correct answer is D: Fluid and electrolyte monitoring. In total parenteral nutrition (TPN), monitoring fluid and electrolyte balance is crucial to prevent complications like dehydration, electrolyte imbalances, and overload. Regular assessment ensures the patient's stability and prevents potential adverse effects. Option A (Evaluation of the peripheral venous site) is important but not essential compared to maintaining fluid and electrolyte balance. Option B (Confirmation that the tube is in the stomach) is irrelevant for a patient receiving TPN as it bypasses the GI tract. Option C (Assessment of the GI tract, including bowel sounds) is not necessary as TPN is given intravenously, bypassing the GI tract altogether.