Nokea
The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?
- A. Stridor
- B. Lung congestion
- C. Occasional pink-tinged sputum
- D. Respiratory rate of 26 breaths per minute
Correct Answer: A
Rationale: Post-extubation after radical neck dissection, stridor (A) indicates airway obstruction (e.g., edema, laryngospasm), requiring immediate RN reporting. Lung congestion (B) or pink sputum (C) suggest fluid but are less urgent. A rate of 26 (D) is elevated but not critical alone. A is correct. Rationale: Stridor signals potential airway compromise, a life-threatening emergency post-neck surgery due to swelling or structural changes, necessitating rapid intervention like reintubation or steroids, per post-operative care standards, unlike less acute findings.
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Which of the following statement is TRUE about deductibles?
- A. Paid after care
- B. Paid before insurance kicks in
- C. Not part of insurance
- D. All of the above
Correct Answer: B
Rationale: Deductibles are paid before insurance kicks in (B), per definition e.g., Mr. Gary's upfront cost. Not after (A), are insurance (C), not all (D) threshold-based. B truly defines deductibles' role, triggering coverage, making it correct.
Examples of patients suffering from impaired awareness include all of the following except:
- A. A semiconscious or over fatigued patient
- B. A disoriented or confused patient
- C. A patient who cannot care for himself at home
- D. A patient demonstrating symptoms of drugs or alcohol withdrawal
Correct Answer: C
Rationale: Inability to self-care at home doesn't inherently impair awareness.
A client with iron-deficiency anemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of foods high in iron.
- B. I should decrease my intake of foods high in iron.
- C. I should increase my intake of foods high in calcium.
- D. I should decrease my intake of foods high in calcium.
Correct Answer: A
Rationale: The correct answer is A: 'I should increase my intake of foods high in iron.' Iron-deficiency anemia is managed by increasing the consumption of iron-rich foods to improve iron levels in the body. Foods high in iron include red meat, poultry, fish, beans, lentils, and iron-fortified cereals. Choices B, C, and D are incorrect because decreasing intake of iron-rich foods or increasing intake of calcium-rich foods would not address the deficiency in iron levels that characterizes iron-deficiency anemia.
A client with chronic kidney disease is being educated by a nurse about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should limit my intake of protein to prevent overworking my kidneys.
- B. I should increase my intake of potassium-rich foods.
- C. I should increase my intake of phosphorus-rich foods.
- D. I should increase my intake of calcium-rich foods.
Correct Answer: A
Rationale: The correct answer is A. In chronic kidney disease, limiting protein intake is crucial to prevent overworking the kidneys. Excessive protein consumption can lead to the accumulation of metabolic waste products that the kidneys struggle to process, worsening kidney function. Therefore, by recognizing the need to restrict protein intake, the client demonstrates an understanding of the dietary management required for their condition. Choices B, C, and D are incorrect. Increasing intake of potassium-rich foods (Choice B) is not recommended in chronic kidney disease as it can lead to hyperkalemia. Similarly, increasing intake of phosphorus-rich foods (Choice C) is not advised because impaired kidneys struggle to excrete phosphorus, leading to elevated levels in the blood. Lastly, increasing intake of calcium-rich foods (Choice D) may not be necessary unless there is a specific deficiency or requirement, as calcium balance is often disrupted in chronic kidney disease.
A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel is a key sign of bacterial meningitis in a 5-month-old, indicating increased intracranial pressure from infection, alongside fever, irritability, and seizures. Periorbital edema isn't typical, a positive Babinski is normal at this age, and a negative scarf sign relates to tone, not pressure. Nurses assess this bulging fontanel urgently, as it signals worsening inflammation, guiding immediate antibiotic and supportive care to prevent brain damage or death in this critical condition.