Nokea
To prepare a patient on the unit for a bronchoscopic procedure, the medical-surgical nurse administers an IV sedative. The nurse then instructs the licensed practical nurse to
- A. educate the patient about the procedure.
- B. give the patient small sips of water only.
- C. measure the patient's blood pressure and heart rate.
- D. take the patient to the bathroom one more time.
Correct Answer: D
Rationale: Emptying the bladder before the procedure is important for comfort and safety.
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Which factor may promote anxiety for a client undergoing a surgical procedure?
- A. Decreased mobility
- B. Unfamiliar environment
- C. Unclear expectations
- D. Decreased alertness
Correct Answer: C
Rationale: The correct answer is C because unclear expectations can increase anxiety in clients facing surgery.
What are clinical manifestations of insomnia (select all that apply)?
- A. Narcolepsy
- B. Fragmented sleep
- C. Long sleep latency
- D. Morning headache
Correct Answer: B
Rationale: The correct answers are B, C, and F. Fragmented sleep, long sleep latency, and difficulty concentrating are common symptoms of insomnia. Narcolepsy (A) is unrelated, morning headache (D) can occur but is less common, and daytime sleepiness (E) is more typical of sleep apnea.
Derek has recently converted his outdoor garage to a gym. He has been exercising frequently in his new gym due to the convenience, even in the extreme heat. He has started taking salt tablets. The physician thinks his current symptoms may be owing to hypernatremia. His physician recognizes these as:
- A. Cardiac arrhythmias,palpitations and sinus arrest.
- B. Weakness,dizziness,abdominal distention, nausea ,vomiting, and diarrhea.
- C. Weight gain,irritability,muscle twitching and decreased myocardial contractility.
- D. Muscle cramps,malaise,constipation,rhabdomyolysis and pupillary constriction.
Correct Answer: B
Rationale: The correct answer is Weakness, dizziness, abdominal distention, nausea, vomiting, and diarrhea (B). Hypernatremia occurs when there is an excess of sodium in the body, often due to dehydration or excessive salt intake. Symptoms include gastrointestinal disturbances, neurological symptoms like confusion and dizziness, and muscle weakness.
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus.
- B. Opening the bottom of the pouch, allowing the flatus to be expelled.
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape.
- D. Assisting the client to ambulate to reduce the flatus in the pouch.
Correct Answer: B
Rationale: Opening the bottom of the pouch allows controlled release of flatus.
A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?
- A. Provide respiratory support.
- B. Place the client in droplet isolation.
- C. Administer antihypertensive medications.
- D. Monitor ascites.
Correct Answer: A
Rationale: Step 1: Inhalation anthrax causes severe respiratory distress.
Step 2: Providing respiratory support helps maintain oxygenation.
Step 3: Oxygen therapy or mechanical ventilation may be needed.
Step 4: This choice directly addresses the critical needs of the client.
Summary:
- B: Droplet isolation is not needed as anthrax is not transmitted person-to-person.
- C: Antihypertensive medications are irrelevant to inhalation anthrax treatment.
- D: Ascites monitoring is not a priority in late-stage inhalation anthrax.