Nokea
The nurse is caring for a client with a history of a hysterectomy. The client complains of hot flashes. The nurse should:
- A. Apply a heating pad
- B. Encourage fluid restriction
- C. Discuss hormone replacement therapy
- D. Administer acetaminophen
Correct Answer: C
Rationale: Hot flashes post-hysterectomy are due to hormonal changes. Discussing hormone replacement therapy with the physician is appropriate. Heating pads, fluid restriction, and acetaminophen are ineffective.
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A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
- A. Apply a lanolin-based lotion to the skin.
- B. Wash the skin with water and pat dry.
- C. Cover the area with a petroleum gauze.
- D. Apply an occlusive dressing to the site.
Correct Answer: B
Rationale: Clean, dry skin is required before hyperbaric oxygen therapy to prevent infection and ensure effective oxygen delivery. Lotions, petroleum, or dressings can interfere or pose fire risks.
Place in correct sequence the steps from 1-7 used when performing tracheostomy suctioning.
- A. Suction the oral cavity.
- B. Auscultate breath sounds for effectiveness.
- C. Set suction control at 80-120 mm Hg.
- D. Ambu or oxygenate at 100% O2
- E. Apply suction while withdrawing the suction catheter.
- F. Turn the head toward the side to be suctioned.
- G. Auscultate breath sounds prior to suctioning.
Correct Answer: G, C, D, F, E, B, A
Rationale: Sequence: Auscultate breath sounds (G), set suction pressure (C), oxygenate (D), turn head (F), apply suction (E), auscultate post-suction (B), suction oral cavity (A) to clean.
The nurse is caring for a client with a history of a pneumothorax who is being discharged. The nurse should teach the client to:
- A. Resume heavy lifting
- B. Avoid swimming
- C. Report chest pain immediately
- D. Sleep on the affected side
Correct Answer: C
Rationale: Chest pain post-pneumothorax may indicate recurrence or complications, requiring immediate reporting. Heavy lifting and swimming are restricted, and sleeping position is not critical.
The nurse is caring for a client with a history of preterm labor. Which medication is most likely to be ordered to halt preterm contractions?
- A. Magnesium sulfate
- B. Nifedipine
- C. Ritodrine
- D. Indomethacin
Correct Answer: B
Rationale: Nifedipine a calcium channel blocker is commonly used as a tocolytic to halt preterm contractions by relaxing uterine smooth muscle. Ritodrine is less used due to side effects magnesium sulfate is more for preeclampsia and indomethacin is used in specific cases.
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.