Nokea
The nurse is reinforcing discharge instructions for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate?
- A. I will ask the health care provider to explain the consequences of your procedure.
- B. This is a common complication that will require you to have a hearing test every year.
- C. This is a common complication; your health care provider will order a consult for the speech pathologist.
- D. This is the reason you are using a special swallowing technique when you eat and drink.
Correct Answer: D
Rationale: The ninth cranial nerve (glossopharyngeal) is involved in swallowing; damage explains the need for special swallowing techniques, directly addressing the client's concern. A avoids providing information. B is incorrect, as the ninth cranial nerve is not related to hearing. C assumes a speech pathology consult, which may not be relevant to swallowing issues caused by nerve damage.
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The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate?
- A. Retractions in the intercostal tissues of the thorax
- B. Chest pain aggravated by respiratory movement
- C. Cyanosis and mottling of the skin
- D. Rapid, shallow respirations
Correct Answer: A
Rationale: Retractions in the intercostal tissues of the thorax. Severe airway obstruction causes extreme intercostal retractions due to increased respiratory effort.
An adult is to have a cardiac catheterization performed tomorrow. When preparing the client for the cardiac catheterization, it is essential for the nurse to do which of the following?
- A. Administer an enema two hours before the procedure
- B. Limit caffeine the day before the procedure
- C. Ask the client about allergies to shellfish
- D. Restrict fat intake the day before the procedure
Correct Answer: C
Rationale: Shellfish allergies may indicate iodine sensitivity, critical for contrast dye used in cardiac catheterization.
The doctor has ordered Polycillin (ampicillin) Suspension 150 mg every 6 hours. The suggested dose for infants is 25-50 mg/kg/day in equally divided doses. The infant weighs 7 kg. The nurse should:
- A. Give the medication as ordered
- B. Give half the amount ordered
- C. Give the ordered amount every 12 hours
- D. Check the order with the doctor
Correct Answer: D
Rationale: The ordered dose (150 mg q6h = 600 mg/day) exceeds the safe range for a 7 kg infant (175-350 mg/day), requiring the nurse to verify the order with the doctor.
The client has a cast applied following a fracture of the femur. The doctor tells the nurse to petal the cast. The nurse is aware that he intends for her to:
- A. Cut the cast down both sides.
- B. Cut a window in the cast.
- C. Cover the edges with cast batting.
- D. Cut the cast down one side.
Correct Answer: C
Rationale: Petaling a cast involves covering the rough edges with adhesive tape or cast batting to prevent skin irritation. Cutting the cast or creating a window is a different procedure.
A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply.
- A. Atorvastatin
- B. Metformin
- C. Metoprolol
- D. Olanzapine
- E. Omeprazole
Correct Answer: C,D
Rationale: Metoprolol, a beta-blocker, can cause orthostatic hypotension, leading to dizziness on standing. Olanzapine, an antipsychotic, is associated with orthostatic hypotension as a side effect. A, B, and E are not commonly linked to orthostatic symptoms; atorvastatin manages cholesterol, metformin controls blood sugar, and omeprazole reduces stomach acid.