Nokea
The start of the luteal phase of the menstrual cycle is marked by:
- A. Menstruation
- B. Pelvic pain
- C. Ovulation
- D. Cramping
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?
- A. Notify the operating room of a potential emergency case.
- B. No action is required at this time; this pulsation can be a normal finding in some clients.
- C. Remove the tracheostomy tube and ventilate the client using a bag-valve-mask.
- D. Stay with the client and ask someone else to contact the provider immediately.
Correct Answer: D
Rationale: The correct answer is D: Stay with the client and ask someone else to contact the provider immediately.
Rationale:
1. Pulsation of the tracheostomy tube with heartbeat indicates the tube is very close to a major blood vessel.
2. Immediate provider notification is crucial to prevent potential complications.
3. Removing the tube without professional guidance can lead to severe bleeding and airway compromise.
4. Contacting the provider promptly ensures timely intervention and appropriate next steps.
Summary:
A: Notifying the operating room is premature and unnecessary at this point.
B: Pulsation may not always be normal and warrants immediate action.
C: Removing the tube without professional guidance can be harmful to the client.
The client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the student nurse under your supervision?
- A. Administer Kayexalate 15 g orally
- B. Administer spironolactone 25 mg orally
- C. Assess ECG strip for tall T waves
- D. Administer potassium 10 mEq orally
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client has received preoperative teaching for a vertical partial laryngectomy. The nurse determines that the teaching has been effective when the client states:
- A. I know I will need special swallowing training after my surgery.'
- B. The quality of my voice will be excellent after surgery.'
- C. I will have very little difficulty swallowing after surgery.'
- D. I may also have to have a radical neck dissection done.'
Correct Answer: C
Rationale: Special swallowing training is required for a client with a supraglottic (horizontal partial) laryngectomy, not a vertical partial laryngectomy. The quality of the client's voice will be altered, but it will be adequate for communication. The client will have minimal difficulty swallowing. A radical neck dissection may be done with a total laryngectomy, not with a partial laryngectomy.
A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. RBC count: 4.8 x 10^6/µL
- D. WBC count: 8.7 x 10^3/µL
Correct Answer: B
Rationale: The correct answer is B: Platelet count: 82,000/µL. A low platelet count (thrombocytopenia) is a serious side effect of heparin therapy, as it can lead to bleeding complications. Platelets are essential for normal blood clotting. Hemoglobin, RBC count, and WBC count are not directly affected by heparin therapy and do not indicate a serious side effect.
Why should a nurse use affective touching cautiously?
- A. It may lead to misunderstandings or discomfort.
- B. It involves the contact required for nursing procedures.
- C. It is used therapeutically when a client is lonesome.
- D. It involves the touch used for sensory-deprived clients.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.