Nokea
The nurse is preparing to care for a client who has returned to the surgical nursing unit following a radical neck dissection.
- A. What is the most appropriate nursing action for a client post-radical neck dissection with a tracheostomy?
- B. Suction the tracheostomy every four hours.
- C. Provide tracheostomy care every 12 hours.
- D. Assess the tracheostomy for patency every shift.
- E. Monitor the tracheostomy site for bleeding or swelling.
Correct Answer: D
Rationale: Following a radical neck dissection, monitoring the tracheostomy site for bleeding or swelling is critical due to the risk of hematoma or airway obstruction, which can be life-threatening. Suctioning and care are important but follow a schedule or as needed, and patency assessment is less urgent than monitoring for surgical complications.
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A woman is in the clinic complaining of urinary frequency, urgency, and pain on urination. Orders include a urine for culture and administration of sulfisoxazole (Gantrisin) and phenazopyridine (Pyridium.) Which action should the nurse take first?
- A. Obtain a clean catch urine from the client.
- B. Ask the client if she is allergic to sulfa drugs.
- C. Administer the sulfisoxazole (Gantrisin).
- D. Administer the phenazopyridine (Pyridium).
Correct Answer: B
Rationale: Checking for sulfa allergies is critical before administering sulfisoxazole, as allergies can cause severe reactions, prioritizing safety.
The nurse is providing home care to a 78-year-old woman who has early dementia. The client tells the nurse, 'My daughter is mean to me.' What should the nurse do initially?
- A. Report suspected elder abuse to the supervisor
- B. Report elder abuse to the authorities
- C. Ask the daughter about the mother's comment
- D. Ask the client to describe what the daughter does to be mean to her
Correct Answer: D
Rationale: The client's statement is very vague and needs to be clarified. Initially, the nurse should ask the client what the daughter does to her that is mean. Examples of behavior are important in evaluating whether the client is the victim of abuse or whether the client's dementia is affecting her perceptions. The nurse does not have enough data at this point to report the client's claim. Initially the nurse should clarify the accusation with the client. After doing that, it would be appropriate to discuss the issue with the daughter.
A client has just been admitted after sustaining a second-degree thermal injury to his right arm.
Which of the following nursing observations is MOST important to report to the doctor?
- A. Pain around the periphery of the injury.
- B. Gastric pH less than 6.0.
- C. Increased edema of the right arm.
- D. An elevated hematocrit.
Correct Answer: B
Rationale: Strategy: Determine how each assessment relates to burns. (1) expected findings in burn wound resolution (2) correct-decrease in gastric pH could indicate hypersecretion of hydrogen ions, predisposing factor to stress ulcer formation (3) expected findings in burn wound resolution (4) expected findings in burn wound resolution
The nurse is caring for a client who is postoperative day 1 after a laparoscopic cholecystectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Right shoulder pain.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-cholecystectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain is normal, shoulder pain is from referred diaphragmatic irritation, and urine output 40 mL/hour is adequate.
The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition?
- A. Solid foods should be introduced at 3-4 months
- B. Whole milk is difficult for a young infant to digest
- C. Fluoridated tap water should be used to dilute milk
- D. Supplemental apple juice can be used between feedings
Correct Answer: B
Rationale: Cow's milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and creates a high renal solute load.