Nokea
To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, what will the nurse do?
- A. Encourage deep breathing
- B. Elevate the head of the bed
- C. Administer oxygen per mask
- D. Position the patient in a side-lying position
Correct Answer: D
Rationale: Side-lying position prevents tongue obstruction and facilitates drainage of secretions.
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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.
What causes an audible wheeze in Mr. Ross’ right lung?
- A. Inflammation of pleural surfaces
- B. Obstruction of the bronchus
- C. Collection of exudate in the pleural cavity
- D. Dilatation of the alveoli
Correct Answer: B
Rationale: Bronchial obstruction leads to turbulent airflow, producing wheezing.
In addition to assessing the degree of the client’s impairment, which of the following information should a nurse obtain from a client who has recently turned blind?
- A. About the client’s diet
- B. About the client’s allergy history
- C. About the client’s family’s medical history
- D. About how the client is coping with the visual problems
Correct Answer: D
Rationale: Understanding the client's emotional and psychological state is crucial for providing holistic care.
What is the main drawback of the botulism antitoxin that the nurse should be aware of?
- A. It causes 9% hypersensitivity.
- B. It requires monthly booster dosages.
- C. It is not available from the CDC.
- D. It is not available as a pre-exposure vaccine.
Correct Answer: D
Rationale: The correct answer is D because botulism antitoxin is not available as a preventive vaccine.
In planning Mrs. Filbert's care during an acute attack of Meniere disease, it would be most important to
- A. encourage her to discuss her feelings about her illness
- B. keep her siderails up and provide assistance when she is permitted out of bed
- C. instruct her about prescribed dietary modifications
- D. encourage her to walk around her room so that her joints will not get stiff
Correct Answer: C
Rationale: Dietary changes, such as reducing salt intake, play a key role in managing Meniere disease by helping control fluid balance in the inner ear.