Nokea
What outcome criterion would best reflect achievement of avoiding infections for Mr. Puff?
- A. Explains reason for avoiding aerosol sprays and powders
- B. Explains reason for avoiding unnecessary physical activity
- C. Lists causative organisms of bronchial infections
- D. States rationale for avoiding crowds when influenza or colds are prevalent
Correct Answer: D
Rationale: Avoiding crowded places minimizes exposure to respiratory pathogens.
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How should the nurse position Mr. Jones’ chest drainage unit while he is transported?
- A. Below the chest level
- B. On the stretcher
- C. The unit should be removed
- D. The tubes should be clamped
Correct Answer: A
Rationale: The correct answer is A: Below the chest level. Positioning the chest drainage unit below the chest level allows for effective drainage of air or fluid from the chest cavity. Placing it above the chest level may cause backflow or air/fluid accumulation. Option B is incorrect as the unit should be secured to prevent dislodging during transport. Option C is incorrect as removing the unit can lead to complications. Option D is incorrect as clamping the tubes can result in a tension pneumothorax. Positioning the unit below the chest level ensures proper drainage and prevents complications during transport.
Yesterday, a male client had a transurethral resection of the prostate (TURP). Today, the client is concerned about the small amount of blood found in his urine. The nurse should explain to the client that the blood:
- A. should not be there on the second day.
- B. will stop when the Foley catheter is removed.
- C. is normal and he should not be concerned.
- D. can be removed by irrigating the bladder.
Correct Answer: C
Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. The client will continue to have a small amount of hematuria even after the Foley catheter is removed. Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. Irrigating the bladder will not remove the hematuria. Irrigation is performed to remove blood clots and to facilitate urinary drainage.
Mary presents difficulty breathing, fatigue, orthopnea, and palpitation, and is diagnosed as having aortic insufficiency. After undergoing aortic valve repair, what medication would you expect her physician to prescribe?
- A. Ativan.
- B. Haldol.
- C. Heparin.
- D. Thorazine.
Correct Answer: C
Rationale: Anticoagulation is often required post-valve repair to prevent clot formation.
Amitriptyline (Elavil) is prescribed for a patient with chronic pain from fibromyalgia. When the nurse explains that this drug is an antidepressant, the patient states that she is in pain, not depressed. What is the nurse’s best response to the patient?
- A. Antidepressants will improve the patient’s attitude and prevent a negative emotional response to the pain.
- B. Chronic pain almost always leads to depression, and the use of this drug will prevent depression from occurring.
- C. Some antidepressant drugs relieve pain by releasing neurotransmitters that prevent pain impulses from reaching the brain.
- D. Certain antidepressant drugs are metabolized in the liver to substances that numb the ends of nerve fibers, preventing the onset of pain.
Correct Answer: C
Rationale: The correct answer is C. Amitriptyline relieves pain by modulating neurotransmitter release, not solely by treating depression.
What should be included in Mr. Ross’s plan of care during radiation therapy if he complains of weakness and lethargy?
- A. Encouraging him to rest more than usual
- B. Monitoring his intake and output
- C. Helping him to accept his condition
- D. Checking his blood pressure daily
Correct Answer: A
Rationale: Rest conserves energy and aids recovery during radiation therapy.