Nokea
The nurse is preparing the client diagnosed with laryngeal cancer for a laryngectomy in the morning. Which intervention is the nurse's priority?
- A. Take the client to the intensive care unit for a visit.
- B. Explain that the client will need to ask for pain medication.
- C. Demonstrate the use of an antiembolism hose.
- D. Find out if the client can read and write.
Correct Answer: D
Rationale: Literacy (D) ensures post-laryngectomy communication (e.g., writing), a priority. ICU visit (A), pain requests (B), and TED hose (C) are secondary.
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Before discharging a client with fractured ribs from the emergency department, which instruction is most important for the nurse to give the client?
- A. Avoid coughing to prevent further injury.
- B. Take deep breaths periodically.
- C. Apply heat to the chest daily.
- D. Sleep in a prone position.
Correct Answer: B
Rationale: Taking deep breaths periodically prevents atelectasis and pneumonia, which are risks with fractured ribs due to shallow breathing.
Which finding best indicates that the sponge bath is having a therapeutic effect on the client?
- A. The client feels more comfortable.
- B. The client begins sweating profusely.
- C. The client's temperature is 101°F (38.3°C).
- D. The client's skin is flushed.
Correct Answer: C
Rationale: A reduced temperature (101°F) directly indicates the sponge bath is effectively lowering the client's fever.
Based on the client's clinical presentation, which drug should the nurse anticipate will be administered intravenously?
- A. Heparin
- B. Aminophylline (Truphylline)
- C. Nitroglycerin (Nitrodisc)
- D. Aspirin
Correct Answer: A
Rationale: Heparin is the standard anticoagulant used to prevent further clot formation in pulmonary embolism.
When the nurse obtains the nasal swab, which action is most accurate?
- A. The nurse dons sterile gloves before obtaining the specimen.
- B. The swab is placed in the anterior portion of the nare and swept superiorly.
- C. The client is asked to blow the nose before the specimen is collected.
- D. The nurse uses separate applicators for each nare.
Correct Answer: D
Rationale: Using separate applicators for each nare prevents cross-contamination and ensures an accurate sample for MRSA screening.
The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse?
- A. The client's ABGs are pH 7.36, Pao2 95, Paco2 38, Hco3 24.
- B. The client's telemetry exhibits occasional premature ventricular contractions (PVCs).
- C. The client's pulse oximeter reading is 90%.
- D. The client's urinary output for the 12-hour shift is 800 mL.
Correct Answer: C
Rationale: SpO2 90% (C) indicates hypoxia in PE, requiring immediate oxygen adjustment. Normal ABGs (A), occasional PVCs (B), and urine output (D) are less urgent.