Nokea
What areas of education should the nurse provide the narrowness to a factory making the cause respiratory irritation to reduce the risk of laryngeal cancer? Select all that apply.
- A. Smoking cessation concurrent with counseling.
- B. HEPA filter use in the home.
- C. Limiting alcohol use.
- D. Brushing teeth after every meal.
- E. Raising the voice to be heard over the noise in the factory.
Correct Answer: A,C
Rationale: Smoking and excessive alcohol use are major risk factors for laryngeal cancer; cessation and moderation reduce risk. HEPA filters address general air quality but not specific carcinogens. Brushing teeth and raising the voice are unrelated to laryngeal cancer risk.
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A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply.
- A. Percuss the abdomen to note resonance and tympany.
- B. Percuss the liver to note lack of dullness.
- C. Monitor the vital signs for fever, tachypnea, and bradycardia.
- D. Assess presence of polyphagia and polydipsia.
- E. Auscultate bowel sounds to note frequency.
Correct Answer: B,C
Rationale: In peritonitis, the nurse should percuss the liver for lack of dullness (B), indicating free air, and monitor vital signs for fever, tachypnea, and tachycardia (not bradycardia) (C). Resonance and tympany, polyphagia, polydipsia, and bowel sound frequency are less specific for peritonitis. CN: Physiological adaptation; CL: Analyze
A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL and a serum potassium level of 3.5 mEq. The physician has ordered 1,000 mL 5% dextrose in water to be infused every 8 hours. Prior to implementing the physician orders, the nurse should contact the physician, explain the situation, provide background information, report the current assessment of the client, and:
- A. Suggest adding potassium to the fluids.
- B. Request an increase in the volume of intravenous fluids.
- C. Verify the order for 5% dextrose in water.
- D. Determine if the client should be placed in isolation.
Correct Answer: C
Rationale: 5% dextrose in water is inappropriate for a hyperglycemic client (325 mg/dL), as it may worsen hyperglycemia. The nurse should verify the order, likely suggesting normal saline instead.
A client is admitted to the emergency department complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to:
- A. Maintain circulation
- B. Manage pain
- C. Prepare the client for emergency surgery
- D. Teach postoperative breathing exercises
Correct Answer: C
Rationale: A large abdominal aortic aneurysm with severe pain suggests impending rupture, requiring emergency surgery to prevent catastrophic bleeding. Preparing the client for surgery is the primary goal, as it addresses the life-threatening condition. Circulation, pain, and breathing exercises are managed perioperatively.
The nurse should ask all clients age 65 or older who are having surgery which question?
- A. Do you have Medicare Part A to help pay for the hospital reimbursement?'
- B. œDo you have an advance directive such as a health care proxy or living will?'
- C. œDo you have extra coverage to help pay for medications?'
- D. œDo you have Medicare Part B to help pay for your expenses?'
Correct Answer: B
Rationale: Asking about an advance directive ensures the client's wishes are documented, especially critical for older adults facing surgical risks, to guide care in case of incapacity.
Which of the following activities indicates that the client with cancer is adapting well to body image changes?
- A. The client names his brother as the person to call if he is experiencing suicidal ideation.
- B. The client discusses changes in body structure and function.
- C. The client discusses the date of his return to work.
- D. The client serves as a volunteer in a client-to-client visitation program.
Correct Answer: D
Rationale: Volunteering in a client-to-client program indicates positive adaptation to body image changes, as it reflects confidence and engagement with others despite physical changes.