Nokea
What considerations and interventions should be used when caring for a client with a hearing impairment?
- A. Use written communication
- B. Speak loudly and slowly
- C. Provide visual aids
- D. All of the above
Correct Answer: D
Rationale: Using multiple strategies ensures effective communication and accommodation for the client's needs.
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You are the charge nurse. Which client is most appropriate to assign to the step-down unit nurse pulled to the intensive care unit for the day?
- A. A 68-year-old client on ventilator with acute respiratory failure and respiratory acidosis
- B. A 72-year-old client with COPD and normal arterial blood gases (ABGs) who is ventilator-dependent
- C. A 56-year-old new admission client with diabetic ketoacidosis (DKA) on an insulin drip
- D. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis
Correct Answer: B
Rationale: A client with stable ABGs and ventilator dependence is less complex compared to other options, making them suitable for a step-down nurse temporarily working in ICU.
What evaluation would help Mr. Jones control his chest pain on inspiration?
- A. Evaluate the intensity and quality of his pain
- B. Explain the cause of his pain
- C. Encourage him to lie on his affected side
- D. Reassure him that the pain will subside
Correct Answer: C
Rationale: Lying on the affected side stabilizes the chest wall, reducing pain during inspiration.
Which of the following imbalances should the nurse check for in a pregnant client with hypertension and cardiac dysrhythmias?
- A. Metabolic acidosis
- B. Hypomagnesemia
- C. Hypernatremia
- D. Hypercalcemia
Correct Answer: B
Rationale: Hypomagnesemia is commonly associated with pregnancy-induced hypertension and can contribute to cardiac dysrhythmias. Magnesium plays a critical role in neuromuscular function and electrolyte balance.
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.
When admitting a client with active tuberculosis to a room on a medical-surgical unit, which of the following room assignments should the nurse make?
- A. A room with air exhaust directly to the outdoor environment
- B. A room with another nonsurgical client
- C. A room in the ICU
- D. A room that is within view of the nurses' station
Correct Answer: A
Rationale: The correct answer is A: a room with air exhaust directly to the outdoor environment. This is to prevent the spread of tuberculosis to other patients and healthcare workers. Tuberculosis is an airborne disease, so proper ventilation is crucial. Choice B is incorrect as placing the client with another nonsurgical client may increase the risk of transmission. Choice C is not ideal as the ICU may have other vulnerable patients. Choice D is also incorrect as the proximity to the nurses' station does not address the need for proper ventilation to prevent the spread of tuberculosis.