Nokea
What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?
- A. The nurse uses a pen pad to communicate with the patient
- B. The nurse provides oral care every 2 hours
- C. The nurse listens for bowel sounds every 4 hours
- D. The nurse suctions as needed and elevates the head of the bed
Correct Answer: D
Rationale: The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.
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Which client is at highest risk for developing a pressure ulcer?
- A. 23 year-old in traction for fractured femur
- B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
- D. 30 year-old who is comatose following a ruptured aneurysm
Correct Answer: C
Rationale: Risk factors for pressure ulcers include: immobility, absence of
sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence,
increased age, decreased immune response. This client has the greatest number of risk
factors.
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
- A. Confusion
- B. Loss of half of the visual field
- C. Shallow respirations
- D. Tonic-clonic seizures
Correct Answer: C
Rationale: In the late stages of Amyotrophic Lateral Sclerosis (A.L.S.), respiratory muscles are affected, leading to shallow respirations. Confusion is not typically associated with A.L.S. Loss of half of the visual field suggests a neurological issue unrelated to A.L.S., while tonic-clonic seizures are not commonly seen in A.L.S. patients. Shallow respirations are a hallmark sign of respiratory muscle weakness in A.L.S. due to the degeneration of motor neurons.
Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.
- A. Providing a low-fat, well-balanced diet.
- B. Teaching the child effective hand-washing techniques.
- C. Notifying the primary health care provider (PHCP) if jaundice is present.
- D. Instructing the parents to avoid administering medications unless prescribed.
Correct Answer: D
Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect. Therefore, the other options are appropriate for the care of a child with hepatitis.
Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent remarks, 'We just don't know how he caught the disease!' The nurse's response is based on an understanding that
- A. AGN is a streptococcal infection that involves the kidney tubules
- B. The disease is easily transmissible in schools and camps
- C. The illness is usually associated with chronic respiratory infections
- D. It is not 'caught' but is a response to a previous B-hemolytic strep infection
Correct Answer: D
Rationale: Acute glomerulonephritis (AGN) is generally considered an immune-complex disease in response to a previous B-hemolytic streptococcal infection, typically occurring 4 to 6 weeks prior. It is not an infectious disease but a noninfectious renal condition. Therefore, the parent's belief that the child 'caught' the disease is inaccurate. Choice A is incorrect because AGN is not a direct streptococcal infection involving the kidney tubules but an immune response to a prior streptococcal infection. Choice B is incorrect as AGN is not easily transmissible in schools and camps. Choice C is incorrect as AGN is not usually associated with chronic respiratory infections but with a previous streptococcal infection.
While eating in the hospital cafeteria, a nurse notices a toddler at a nearby table choking on a piece of food and appearing slightly blue. What is the appropriate initial action to take?
- A. Begin mouth-to-mouth resuscitation
- B. Give the child water to help with swallowing
- C. Perform 5 abdominal thrusts
- D. Call for the emergency response team
Correct Answer: C
Rationale: When a toddler is choking on a piece of food and appears blue, it indicates airway obstruction. The appropriate initial action should be to perform 5 abdominal thrusts. This technique can help dislodge the obstructing object and clear the airway. Initiating mouth-to-mouth resuscitation is not recommended as the first step in a choking emergency, especially in children. Giving water may not be effective and can worsen the situation by causing further blockage. Calling the emergency response team should be considered if the abdominal thrusts are unsuccessful in clearing the airway.