Nokea
The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give 'hand-off reports' at which of the following times? Select all that apply.
- A. Change of shift.
- B. Change of nurses.
- C. When nurse goes to lunch.
- D. When unit clerk goes to a staff meeting.
- E. When new medication orders are written.
Correct Answer: A,B,C
Rationale: Hand-off reports are critical at change of shift, change of nurses, and when the nurse goes to lunch to ensure continuity of care and client safety.
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Experimental and epidemiologic evidence suggests that a high-fat diet increases the risk of several cancers. Which of the following cancers is linked to a high-fat diet?
- A. Ovarian.
- B. Lung.
- C. Colon.
- D. Liver.
Correct Answer: C
Rationale: A high-fat diet is strongly associated with an increased risk of colon cancer, as it can promote inflammation and alter gut microbiota, contributing to carcinogenesis.
The nurse teaches the client with an ileal conduit measures to prevent a urinary loss. Which of the following measures would be most effective?
- A. Avoid people with respiratory tract infections.
- B. Maintain a daily fluid intake of 2,000 to 3,000 mL.
- C. Use sterile technique to change the appliance.
- D. Irrigate the stoma daily.
Correct Answer: B
Rationale: Maintaining high fluid intake (2,000-3,000 mL) prevents urinary stasis and infection, the most effective measure for reducing urinary loss risk.
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first?
- A. Prepare for transcutaneous pacing.
- B. Prepare to defibrillate the client at 200 joules.
- C. Administer atropine 0.5 mg I.V. push.
- D. Schedule the operating room for insertion of a permanent pacemaker.
Correct Answer: A
Rationale: Third-degree heart block with a rate of 35 bpm and hypotension requires immediate transcutaneous pacing to restore adequate heart rate and perfusion.
The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to:
- A. Decreased blood flow
- B. Increased blood flow
- C. Increased blood viscosity
- D. Increased blood viscosity
Correct Answer: A
Rationale: In PVD, decreased blood flow to the extremities limits oxygen delivery to muscles, reducing exercise tolerance. In heart failure, reduced cardiac output further exacerbates this limitation, as the heart cannot meet increased oxygen demands during activity. Increased blood flow or viscosity is not relevant, and the options are repeated incorrectly in the document.
A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to:
- A. Begin total parenteral nutrition.
- B. Start a cutdown infusion.
- C. Administer tube feedings.
- D. Perform a tracheotomy.
Correct Answer: D
Rationale: Tracheotomy equipment is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy.