Nokea
A client after a bronchoscopy.
The nurse would be MOST concerned if which of the following was observed?
- A. Depressed gag reflex.
- B. Sputum streaked with blood.
- C. Tachypnea.
- D. Complaints of a sore throat.
Correct Answer: C
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) would cause a complication if client is given fluids before the gag reflex has returned (2) common for a few days after a biopsy (3) correct-client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions (4) expected after this procedure
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The nurse is teaching a client how to perform self-monitoring blood glucose (SMBG) using a blood glucose monitor.
Which of the following actions, if performed by the client, indicates to the nurse the need for further teaching?
- A. The client lets her hand dangle before sticking her finger with the lancet.
- B. The client sticks her finger on the side of the distal phalanx.
- C. The client touches the strip with a large drop of blood hanging from her fingertip.
- D. The client milks her finger after sticking it.
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) helps to facilitate venous congestion (2) less painful than the center of the fingertip (3) blood should sit on the strip like a raindrop, smearing alters the reading (4) correct-forces interstitial fluid to mix with capillary blood and dilutes the blood
Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce information about cancers to a group of young adults?
- A. You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods.
- B. Prostate cancer is the most common cancer in American men with results to threaten sexuality and life.
- C. Colorectal cancer is the second-leading cause of cancer-related deaths in the United States.
- D. Lung cancer is the leading cause of cancer deaths in the United States. Yet it's the most preventable of all cancers.
Correct Answer: A
Rationale: It is recommended that only red meat be limited for the prevention of stomach cancer. All of the other statements offer correct information.
The nurse is performing in-service education about the use of the defibrillator.
Which of the following statements, if made by the nurse, is MOST important?
- A. Do not touch the bed when using the defibrillator.
- B. Check the defibrillator every 24 hours.
- C. Do not leave the defibrillator plugged in.
- D. Do not place the paddles over the electrodes.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-is a priority to prevent accidental countershock (2) equipment should be checked every eight hours (3) equipment should remain plugged in at all times (4) is not a priority; while this should not occur, it can be safely done
A clear liquid diet is ordered for an adult following surgery. All of the following are on the client's tray. Which should be removed by the nurse?
- A. Ice cream
- B. Beef broth
- C. Apple juice
- D. Iced tea
Correct Answer: A
Rationale: Ice cream is not a clear liquid, as it contains dairy solids, and must be removed from a clear liquid diet tray.
A young female with recent ileostomy due to ulcerative colitis. A middle-aged male with elevated temperature and chronic pancreatitis. A teenager in hypovolemic shock following a crushing injury to the chest. A child with compound fracture of the right femur and massive laceration of the left arm.
The nurse would identify which of the following patients as a likely candidate for developing acute renal failure?
- A. A young female with recent ileostomy due to ulcerative colitis.
- B. A middle-aged male with elevated temperature and chronic pancreatitis.
- C. A teenager in hypovolemic shock following a crushing injury to the chest.
- D. A child with compound fracture of the right femur and massive laceration of the left arm.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to acute renal failure. (1) usually ileostomy clients do not experience severe hypovolemia, which would lead to renal failure problems (2) this type of infection and inflammation does not lead to acute renal failure (3) correct-common cause of acute renal failure is renal ischemia precipitated by hypovolemia or heart failure (4) femoral fractures are more likely to lead to fat embolism than acute renal failure