Nokea
The nurse should place a client being admitted to the hospital with suspected tuberculosis on what type of isolation?
- A. Standard precautions.
- B. Contact precautions.
- C. Droplet precautions.
- D. Airborne precautions.
Correct Answer: D
Rationale: Tuberculosis requires airborne precautions due to droplet nuclei transmission. Standard, contact, and droplet precautions are insufficient.
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After a laminectomy, the client states, 'The physician said that I can do anything I want to.' Which of the following client-stated activities indicates the need for further teaching?
- A. Drying the dishes.
- B. Sitting outside on firm cushions.
- C. Making the bed walking from side to side.
- D. Sweeping the front porch.
Correct Answer: D
Rationale: Sweeping involves twisting and bending, which can strain the surgical site post-laminectomy.
Complications associated with a tracheostomy tube include:
- A. Decreased cardiac output.
- B. Damage to the laryngeal nerve.
- C. Pneumothorax.
- D. Acute respiratory distress syndrome (ARDS).
Correct Answer: C
Rationale: Pneumothorax is a potential complication of tracheostomy tube placement due to possible injury to the lung or pleural space during insertion or maintenance.
The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?
- A. Use of a fracture bedpan.
- B. Checks for redness over the ischial tuberosity.
- C. Elevation of the head of bed no more than 25 degrees.
- D. Personal hygiene with a complete bed bath.
Correct Answer: C
Rationale: Elevating the head of the bed beyond 25 degrees can disrupt traction alignment, making it least appropriate.
A 70-year-old male with the diagnosis of claudication has been hospitalized for an evaluation of his increasingly impaired mobility and complaints of pain. The client tells the nurse that he can no longer walk a block without having severe pain in his left calf and foot. Based on these data, which nursing diagnosis would be most appropriate for this client?
- A. Activity intolerance related to decreased blood supply and pain
- B. Self-care deficit related to increased leg pain
- C. Ineffective coping related to chronic pain
- D. Impaired skin integrity related to poor circulation
Correct Answer: A
Rationale: Activity intolerance due to decreased blood supply and pain is the most appropriate nursing diagnosis, as claudication (pain during walking) directly results from inadequate arterial blood flow, limiting mobility. The other diagnoses may apply but are less specific to the described symptoms.
Cushing's disease is manifested by the excessive secretion of corticosteroids. The hormones involved are:
- A. Glucocorticoids and aldosterone.
- B. Adrenocorticotropic hormone (ACTH).
- C. Glucocorticoids, aldosterone, and androgens.
- D. Catecholamines.
Correct Answer: C
Rationale: Cushing's disease involves excess glucocorticoids, aldosterone, and androgens due to adrenal hypersecretion.