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Upon hearing that he has acute pericarditis, the patient asks how he could have contracted the disease. The best response is
- A. The upper respiratory viral infection that you experienced a couple of weeks ago could have led to acute pericarditis.
- B. It is a genetic condition that you received from your father.
- C. It is a genetic condition that you received from your mother.
- D. It is the weakening of the left side of your heart.
Correct Answer: A
Rationale: Viral infections are a common cause of acute pericarditis.
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While recovering from the anesthetic, what is the best position for Mrs. West?
- A. Supine with legs fully extended
- B. Prone with head turned to the side
- C. Lateral Sims with legs flexed
- D. Trendelenburg with head to the side
Correct Answer: D
Rationale: The correct answer is D: Trendelenburg with head to the side. This position helps prevent aspiration by promoting drainage of secretions from the mouth and reducing the risk of airway obstruction. Placing the patient in Trendelenburg position with the head to the side also helps facilitate proper blood flow and ventilation. Supine with legs fully extended (A) may increase the risk of airway obstruction and aspiration. Prone with head turned to the side (B) may obstruct the airway and hinder breathing. Lateral Sims with legs flexed (C) is not suitable for a patient recovering from anesthesia as it may not provide optimal airway clearance and respiratory support.
To communicate with a patient who does not speak the dominant language, the nurse should
- A. Speak slowly and enunciate clearly in a slightly louder voice.
- B. Use gestures and pantomime words while verbalizing specific words.
- C. Use family members rather than strangers as interpreters to increase the patient’s feeling of comfort.
- D. Use a dictionary or phrase books that translate from both the nurse’s language and the patient’s language.
Correct Answer: A
Rationale: Speaking slowly, using gestures, and utilizing translation tools facilitate effective communication. Using family members as interpreters can introduce bias and inaccuracies.
Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?
- A. Position the head of the client's bed flat
- B. Turn the client every 4 hours
- C. Brush the client's teeth with a suction toothbrush every 12 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct Answer: C
Rationale: The correct answer is C: Brush the client's teeth with a suction toothbrush every 12 hours. This is crucial in reducing the risk of ventilator-associated pneumonia as it helps prevent the buildup of bacteria in the oral cavity, which can be aspirated into the lungs. Brushing the teeth regularly maintains oral hygiene, decreasing the chances of infection.
A: Positioning the head of the client's bed flat can increase the risk of aspiration and pneumonia.
B: Turning the client every 4 hours is important for preventing pressure ulcers but does not directly reduce the risk of ventilator-associated pneumonia.
D: Providing humidity within the ventilator tubing is important for preventing mucous plugs but does not directly address oral hygiene, which is key in preventing pneumonia.
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.
When teaching a client with chronic obstructive pulmonary disease who will start using fluticasone via MDI twice daily, which instruction should the nurse include?
- A. Monitor your heart rate before each dose.
- B. Inspect your mouth for lesions daily.
- C. Do not use this medication to relieve an acute attack.
- D. Do not skip the morning dose even if symptom-free.
Correct Answer: B
Rationale: The correct answer is B: Inspect your mouth for lesions daily. This instruction is essential because fluticasone, a corticosteroid, can cause oral thrush as a side effect. By inspecting the mouth daily, the client can detect any lesions early and seek appropriate treatment. Monitoring heart rate (A) is not necessary for fluticasone use, as it does not typically affect heart rate. While it is important not to skip doses (D), the specific instruction about the morning dose is not as crucial. Avoiding the use of fluticasone for acute attacks (C) is correct, but it is not the most important instruction in this scenario.