Nokea
Tom arrives in the Emergency Room (ER) and is unable to move his legs as a result of an automobile accident that occurred 30 minutes ago. You respond by saying
- A. Swelling due to the initial trauma prevents you from moving your legs.
- B. There are good rehabilitation centers that will help restore sensation to your legs.
- C. Swelling due to the initial trauma may make the injury seem more severe than it actually is. A more accurate assessment will be made once the swelling goes down.
- D. You should have been wearing your seatbelt.
Correct Answer: C
Rationale: Initial swelling can mask the true extent of spinal injuries.
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A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?
- A. Prevent aspiration.
- B. Ensure adequate nutrition.
- C. Promote oral hygiene.
- D. Relieve the client's pain.
Correct Answer: A
Rationale: The correct answer is A: Prevent aspiration. This is the priority because with intermaxillary fixation, the client is unable to open their mouth, increasing the risk of aspiration. Aspiration can lead to serious complications, such as pneumonia. Ensuring the client's airway is clear and they are able to breathe properly should be the top priority.
Summary:
- B: Ensuring adequate nutrition can be important, but preventing aspiration takes precedence.
- C: Promoting oral hygiene is important but not as urgent as preventing aspiration.
- D: Relieving the client's pain is essential, but ensuring their safety from aspiration is the priority.
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct Answer: A
Rationale: Step 1: Increased respiratory rate from 18 to 44/min indicates potential respiratory distress, a serious complication post-fracture.
Step 2: Rapid breathing can signify hypoxemia, pulmonary embolism, or infection, requiring immediate intervention.
Step 3: Increased oral temperature and blood pressure within normal range are not as critical as respiratory distress.
Step 4: A slight increase in heart rate is common after a fracture and not indicative of a serious complication.
Which tubes drain gastric contents (select all that apply)?
- A. T-tube
- B. Hemovac
- C. Nasogastric tube
- D. Indwelling catheter
Correct Answer: D
Rationale: Nasogastric and gastrointestinal tubes drain gastric contents effectively.
Patient teaching for risk reduction of skin cancer should include
- A. Having suspicious moles checked by a dermatologist.
- B. Daily sun exposure every 1/2 hour.
- C. Daily sun exposure of 1 hour to build tolerance.
- D. Applying moisturizer.
Correct Answer: A
Rationale: Regular monitoring of moles and avoiding excessive sun exposure are vital for skin cancer prevention.
A 35-year-old client is admitted for elective tubal ligation. During the preoperative teaching, the client states, 'The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?' The best explanation by the nurse is that balanced anesthesia:
- A. is a type of regional anesthesia.
- B. uses equal amounts of inhalation agents and liquid agents.
- C. does not depress the central nervous system.
- D. is a combination of several anesthetic agents or drugs, which produce a smooth induction with minimal complications.
Correct Answer: D
Rationale: A regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. Varying amounts of anesthetic agents are used when employing balanced anesthesia. The amounts used depend on the age, weight, condition of the client and the surgical procedure. General anesthesia is a drug induced depression of the central nervous system, which produces loss of consciousness and decreased muscle activity. Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications.