Nokea
The nurse is creating a discharge plan for a postoperative client who had a unilateral adrenalectomy. What area of instruction should the nurse include in the plan to minimize the client's risk for injury?
- A. Teaching the client to maintain a diabetic diet
- B. Encouraging the adoption of a realistic exercise routine
- C. Providing a detailed list of the early signs of a wound infection
- D. Explaining the need for lifelong replacement of all adrenal hormones
Correct Answer: C
Rationale: A client who had a unilateral adrenalectomy (one adrenal gland was removed) will be placed on corticosteroids temporarily to avoid a cortisol deficiency; lifelong replacement is not necessary. Corticosteroids will be gradually weaned in the postoperative period until they are discontinued. Also, because of the anti-inflammatory properties of corticosteroids produced by the adrenals, clients who undergo an adrenalectomy are at increased risk of developing wound infections. Because of this increased risk of infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection seems to be present.
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The nurse caring for a child admitted to the hospital with a diagnosis of viral pneumonia describes the treatment plan to the parents. The nurse determines the need for further teaching when the parents make which statement regarding the treatment?
- A. We need to be very careful since oxygen is extremely flammable.
- B. It's important that the child isn't allergic to the antibiotic that is prescribed.
- C. It's difficult to watch the needle be inserted when intravenous fluids are needed.
- D. Chest physiotherapy will loosen the congestion, so coughing will clear the lungs.
Correct Answer: B
Rationale: The therapeutic management for viral pneumonia is supportive. Antibiotics are not given unless the pneumonia is bacterial. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and intravenous fluids.
A client has had a nasointestinal (NI) tube in place for 24 hours. Which assessment finding indicates that the tube is properly located in the intestine?
- A. Bowel sounds are absent.
- B. The client denies being nauseous.
- C. Aspirate from the tube has a pH of 7.
- D. The abdominal x-ray indicates that the end of the tube is above the pylorus.
Correct Answer: C
Rationale: The nasogastric (NG) or NI tube is used to decompress the intestine and correct a bowel obstruction. Nausea should subside as decompression is accomplished. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is alkaline (7 or higher). Although bowel sounds will be abnormal in the presence of obstruction, the presence or absence of bowel sounds is not associated with the location of the tube. The end of the tube should be located in the intestine (below the pylorus). Location of the tube can also be determined by radiographs.
The nurse is developing a plan of care for an older client diagnosed with type 1 diabetes mellitus who is also experiencing acute gastroenteritis. To maintain food and fluid intake in order to prevent dehydration, which action should the nurse plan to include?
- A. Offering only water until the client is able to tolerate solid foods
- B. Withholding all fluids until vomiting has ceased entirely for at least 4 hours
- C. Encouraging the client to take 8 to 12 ounces of fluid every hour while awake
- D. Maintaining a clear liquid diet for at least 5 days before advancing to solid foods
Correct Answer: C
Rationale: Dehydration needs to be prevented in the client with type 1 diabetes mellitus because of the risk of diabetic ketoacidosis (DKA). Small amounts of fluid may be tolerated, even when vomiting is present. The client should be offered liquids containing both glucose and electrolytes. The diet should be advanced as tolerated and include a minimum of 100 to 150 g of carbohydrates daily.
Which nursing assessment question should be asked to help determine the client's risk for developing malignant hyperthermia in the perioperative period?
- A. Have you ever had heat exhaustion or heat stroke?
- B. What is the normal range for your body temperature?
- C. Do you or any of your family members have frequent infections?
- D. Do you or any of your family members have problems with general anesthesia?
Correct Answer: D
Rationale: Malignant hyperthermia is a genetic disorder in which a combination of anesthetic agents (the muscle relaxant succinylcholine and inhalation agents such as halothanes) triggers uncontrolled skeletal muscle contractions that can quickly lead to a potentially fatal hyperthermia. Questioning the client about the family history of general anesthesia problems may reveal this as a risk for the client. Options 1, 2, and 3 are unrelated to this surgical complication.
The nurse evaluates a client after treatment for carbon monoxide poisoning following a burn injury. The nurse should document that the treatment was effective if which finding was present? Select all that apply.
- A. The client is sleeping soundly.
- B. The client is awake and talking.
- C. Respiratory rate is 26 breaths/minute.
- D. The client's heart rate is 84 beats/minute.
- E. Carboxyhemoglobin levels are less than 5%.
- F. The heart monitor shows normal sinus rhythm.
Correct Answer: D,E,F
Rationale: Normal carboxyhemoglobin levels are less than 5% for a nonsmoking adult. Clients can be awake and talking with abnormally high levels. The symptoms of carbon monoxide poisoning are tachycardia, tachypnea, and central nervous system depression.