Nokea
What does a nurse assess postoperatively in a client with a nasal fracture?
- A. Allergic reaction
- B. Airway obstruction
- C. Extreme sense of smell
- D. Stridor
Correct Answer: B
Rationale: The correct answer is B. Airway obstruction is a critical concern after a nasal fracture due to potential swelling or displacement of bone fragments. A (allergic reaction) is unrelated. C (extreme sense of smell) is not a concern postoperatively. D (stridor) indicates severe airway compromise but is less common in nasal fractures.
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After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must:
- A. Monitor fluctuations in the water-seal chamber.
- B. Clamp the chest tube once every shift.
- C. Encourage coughing and deep breathing.
- D. Milk the chest tube every 2 hours.
Correct Answer: C
Rationale: Step-by-step rationale for why "Encourage coughing and deep breathing" (Choice C) is the correct answer:
1. After pneumonectomy, patient is at risk for lung complications.
2. Encouraging coughing and deep breathing helps prevent atelectasis and pneumonia.
3. It promotes lung expansion and clears secretions.
4. This intervention supports respiratory function and aids in recovery.
Summary of why the other choices are incorrect:
A. Monitoring fluctuations in the water-seal chamber (Choice A) is important for assessing the status of the chest tube drainage, but not the immediate priority for patient care post-pneumonectomy.
B. Clamping the chest tube once every shift (Choice B) is not recommended as it can lead to complications like tension pneumothorax.
D. Milking the chest tube every 2 hours (Choice D) is unnecessary and can cause trauma to the lung tissue and increase the risk of infection.
You are the team leader RN working with a student nurse. The student nurse is to teach the client how to use a multidose inhaler without a spacer. Put the steps that the student nurse should teach the client in correct order.
- A. Remove the inhaler cap and shake the inhaler.
- B. Tilt your head back and breathe out fully.
- C. Press down firmly on the canister and breathe deeply through your mouth.
- D. Wait at least 1 minute between puffs.
Correct Answer: D
Rationale: The correct order is: A (remove cap and shake), B (tilt head back and breathe out), C (press down and breathe in), D (wait between puffs). This sequence ensures proper inhaler technique.
When teaching a patient with heart failure on a 2000-mg sodium diet. Which foods should the nurse recommend limiting?
- A. Chicken
- B. Fresh spinach
- C. Eggs
- D. Milk
Correct Answer: D
Rationale: The correct answer is D: Milk. Milk is a high sodium food and can contribute significantly to a patient's daily sodium intake. For a patient on a 2000-mg sodium diet, it is crucial to limit high sodium foods like milk to prevent fluid retention and worsening of heart failure symptoms. Other choices (A, B, C) are lower in sodium compared to milk. Chicken, fresh spinach, and eggs are generally good protein sources with lower sodium content and can be included in moderation in a 2000-mg sodium diet for a heart failure patient.
Carbon dioxide and water combine to form
- A. hydrochloric acid
- B. oxygen
- C. carbonic acid
- D. carbaminohemoglobin
Correct Answer: C
Rationale: The correct answer is C: carbonic acid. When carbon dioxide and water combine, they form carbonic acid through a chemical reaction known as hydration. This process is essential for the transportation of carbon dioxide in the blood and plays a crucial role in maintaining the body's pH balance. Hydrochloric acid (A) is formed by the reaction of hydrogen chloride gas with water. Oxygen (B) is not a product of the reaction between carbon dioxide and water. Carbaminohemoglobin (D) is a compound formed by the binding of carbon dioxide to hemoglobin in red blood cells, not a direct product of the reaction between carbon dioxide and water.
A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications doesn't the nurse plan to teach the client?
- A. Absorptive atelectasis
- B. Combustion
- C. Dried mucous membranes
- D. Alveolar recruitment
Correct Answer: D
Rationale: The correct answer is D - Alveolar recruitment. This is because alveolar recruitment is actually a benefit of home oxygen therapy, not a complication. It helps improve oxygenation by opening up collapsed alveoli.
A - Absorptive atelectasis is a potential complication where nitrogen is absorbed from the alveoli leading to collapse. B - Combustion is a hazard due to oxygen's flammability. C - Dried mucous membranes is a common complication of oxygen therapy due to the drying effect of oxygen.