Nokea
What is the best example of documentation of patient teaching regarding wound care?
- A. The patient was instructed about care of wound and dressing changes.
- B. The patient demonstrated correct technique of wound care following instruction.
- C. The patient and caregiver verbalize that they understand the purposes of wound care.
- D. Written instructions regarding wound care and dressing changes were given to the patient.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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In which circumstance should a nurse avoid using midline and midclavicular sites for IV therapy?
- A. To administer solutions with a pH greater than 5 and less than 9.
- B. To administer antineoplastic chemotherapy.
- C. To administer slow,low-volume infusions.
- D. To administer solutions with an osmolality less than 500 mOsm/L.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone secretion (SIADH). After reporting symptoms of weight gain, weakness, and nausea and vomiting to the physician, you would anticipate which initial order for the treatment of this patient?
- A. A fluid bolus as ordered.
- B. Fluid restrictions as ordered.
- C. Urinalysis as ordered.
- D. Sodium-restricted diet as ordered.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?
- A. Document findings.
- B. Administer O2 therapy.
- C. Position client in high-Fowler's position.
- D. Administer prescribed albuterol.
Correct Answer: A
Rationale: The correct answer is A: Document findings. This is important because the harsh hollow sound over the trachea and larynx could indicate a potential emergency or serious condition like an airway obstruction or laryngeal edema. Documenting findings helps in providing clear communication to other healthcare professionals and ensures proper follow-up care. Administering O2 therapy (B) or albuterol (D) without a clear understanding of the underlying issue could be harmful. Positioning the client in high-Fowler's position (C) may not directly address the potential emergency at hand.
The client has received preoperative teaching for a vertical partial laryngectomy. The nurse determines that the teaching has been effective when the client states:
- A. I know I will need special swallowing training after my surgery.'
- B. The quality of my voice will be excellent after surgery.'
- C. I will have very little difficulty swallowing after surgery.'
- D. I may also have to have a radical neck dissection done.'
Correct Answer: C
Rationale: Special swallowing training is required for a client with a supraglottic (horizontal partial) laryngectomy, not a vertical partial laryngectomy. The quality of the client's voice will be altered, but it will be adequate for communication. The client will have minimal difficulty swallowing. A radical neck dissection may be done with a total laryngectomy, not with a partial laryngectomy.
On the first encounter with the patient, the nurse will complete a general survey. Which features are included (select all that apply)?
- A. Mental state and behavior
- B. Lung sounds and bowel tones
- C. Body temperature and pulses
- D. Speech and body movements
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.