Nokea
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.
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How can a nurse foster effective coping skills?
- A. Deep breathing exercises
- B. Avoid social interactions
- C. Ignore stressors
- D. Increase workload
Correct Answer: B
Rationale: The correct answer is B because it is the most appropriate response based on physiological and medical principles.
During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?
- A. Dysphagia
- B. Hoarseness
- C. Dyspnea
- D. Weight loss
Correct Answer: B
Rationale: The correct answer is B: Hoarseness. Hoarseness is a common early manifestation of laryngeal cancer due to vocal cord involvement. Smoking is a major risk factor for laryngeal cancer. Dysphagia (choice A) is more commonly associated with esophageal cancer. Dyspnea (choice C) is usually a late manifestation of laryngeal cancer when it causes airway obstruction. Weight loss (choice D) may occur later in the disease progression but is not typically an early sign. Thus, hoarseness is the most likely early manifestation due to its direct connection to the vocal cords and smoking history.
The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Absence of fluid in the drainage tubing
- C. Continuous bubbling within the water seal chamber
- D. Equal amounts of fluid drainage in each collection chamber
Correct Answer: A
Rationale: The correct answer is A: Fluctuation of the fluid level within the water seal chamber. This indicates proper chest tube function as it shows that the system is maintaining the desired pressure and allowing for adequate drainage without obstruction. When the patient breathes in and out, the fluid level fluctuates due to changes in intrathoracic pressure.
Explanation of other choices:
B: Absence of fluid in the drainage tubing - This would indicate a problem with drainage, possibly due to a blockage in the tubing.
C: Continuous bubbling within the water seal chamber - This would suggest an air leak in the system, which is not ideal as it can lead to lung collapse.
D: Equal amounts of fluid drainage in each collection chamber - While equal drainage is good, it does not specifically indicate proper chest tube function like the fluctuation of the fluid level does.
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.
The first priority to care for the patient with a new fracture includes assessing
- A. Respiratory rate and effort, as well as pulse.
- B. The fracture site for bleeding.
- C. For signs of infection at the wound site of an open fracture.
- D. For circulation and sensation distal to the fracture site.
Correct Answer: D
Rationale: Assessing circulation and sensation ensures no compromise to distal structures.