Nokea
The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
- A. Cough and deep breathe every 2 hours.
- B. Place the client in contact isolation.
- C. Provide a diet high in protein.
- D. Institute seizure precautions.
Correct Answer: A
Rationale: Encouraging coughing and deep breathing helps prevent pulmonary complications.
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What nursing measure assumes priority for Mr. Johnson with sudden diarrhea and high fever?
- A. Determine if he had been working on an air-conditioning unit of a high-rise building
- B. Place the patient in isolation
- C. Monitor respiratory status carefully and observe for signs of hypoxia
- D. Begin discharge teaching
Correct Answer: C
Rationale: The correct answer is C, to monitor respiratory status and observe for signs of hypoxia. This is because sudden diarrhea and high fever can indicate a potential infectious illness, which can lead to respiratory complications such as pneumonia. Monitoring respiratory status is crucial to detect any signs of respiratory distress or hypoxia early on.
A: Determining his work on an air-conditioning unit is not a priority at this time as it does not directly address his immediate health concerns.
B: Placing the patient in isolation may be necessary later depending on the diagnosis, but it is not the priority at this moment.
D: Beginning discharge teaching is not appropriate as the patient is currently experiencing acute symptoms that require immediate attention.
In summary, monitoring respiratory status is the priority to ensure early detection and intervention for any potential respiratory complications in a patient with sudden diarrhea and high fever.
Which measures or drugs may be effective in controlling pain in the physiologic pain process stage of transduction (select all that apply)?
- A. Distraction
- B. Corticosteroids
- C. Epidural opioids
- D. Local anesthetics
Correct Answer: D
Rationale: The correct answers are D, Local anesthetics, distraction, and NSAIDs target the transduction stage.
A client is 1 day postoperative following a lobectomy with a chest tube drainage system in place. Which finding by the nurse indicates a need for intervention?
- A. Chest tube eyelets not visible
- B. Continuous bubbling in the suction control chamber
- C. Presence of tidal fluctuation in the water seal chamber
- D. Development of subcutaneous emphysema
Correct Answer: D
Rationale: The correct answer is D: Development of subcutaneous emphysema. This finding indicates air leakage, which can lead to potential complications like tension pneumothorax. Subcutaneous emphysema is a serious concern that requires immediate intervention.
A: Chest tube eyelets not visible - This is not a concerning finding as long as the chest tube is properly secured and functioning.
B: Continuous bubbling in the suction control chamber - This can indicate proper functioning of the system.
C: Presence of tidal fluctuation in the water seal chamber - This indicates that the system is working correctly, with the water seal chamber fluctuating with the patient's breathing.
Which chief complaint is NOT desirable for recording on the client’s chart?
- A. CC: “cough and temperature elevation,” 2 days duration
- B. CC: “passing black stools,” 1 day duration
- C. CC: “substernal pain,” 2 hours duration
- D. Reason for contact: “physical examination for college”
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Chief complaints should be symptoms or concerns related to the client's health issues.
2. "Physical examination for college" is not a specific symptom or health concern.
3. Chief complaints guide healthcare providers in assessing and treating the client.
4. Recording irrelevant chief complaints can lead to confusion in diagnosis and treatment.
Summary of Incorrect Choices:
A: Describes specific symptoms, suitable for recording.
B: Describes a specific symptom (black stools), suitable for recording.
C: Describes a specific symptom (substernal pain), suitable for recording.
Which technique facilitates interactions between the nurse and client?
- A. Ask questions that can be answered with yes or no.
- B. Sit within the client’s comfort zone.
- C. Avoid making eye contact.
- D. Address clients by their first names.
Correct Answer: B
Rationale: Respecting personal space enhances trust and comfort during interactions.