Nokea
What would be useful in helping Mr. Jackson prepare for chest tube insertion?
- A. Explain the etiology of his condition
- B. Ask if he has any questions about the insertion procedure and its purpose
- C. Teach him to splint his chest wall
- D. Reassure him that the procedure is painless
Correct Answer: C
Rationale: Splinting minimizes movement and discomfort during the procedure.
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What is the primary role of lubricating eye drops?
- A. Moisten the eyes
- B. Treat infections
- C. Correct refractive errors
- D. None of the above
Correct Answer: A
Rationale: Lubricating drops relieve dryness and discomfort by moisturizing the ocular surface.
During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse's initial action is to
- A. continue the hourly neurologic assessments.
- B. inform the neurosurgeon of the patient's status.
- C. prepare the patient for emergency surgery.
- D. recheck the patient's neurologic status in 15 minutes.
Correct Answer: B
Rationale: Neurological changes could indicate worsening intracranial pressure, necessitating immediate physician notification.
A 35-year-old client is admitted for elective tubal ligation. During the preoperative teaching, the client states, 'The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?' The best explanation by the nurse is that balanced anesthesia:
- A. is a type of regional anesthesia.
- B. uses equal amounts of inhalation agents and liquid agents.
- C. does not depress the central nervous system.
- D. is a combination of several anesthetic agents or drugs, which produce a smooth induction with minimal complications.
Correct Answer: D
Rationale: A regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. Varying amounts of anesthetic agents are used when employing balanced anesthesia. The amounts used depend on the age, weight, condition of the client and the surgical procedure. General anesthesia is a drug induced depression of the central nervous system, which produces loss of consciousness and decreased muscle activity. Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications.
A nurse caring for a patient in the intensive care unit (ICU) implements strategies to create an environment conducive to sleep. Which strategy would be most effective?
- A. Turning off the lights in the room during the night
- B. Having the television on at all times for background noise
- C. Silencing the alarms on the bedside monitor and infusion pumps
- D. Administering ordered analgesics around the clock, even if the patient denies pain
Correct Answer: A
Rationale: The correct answer is A. Turning off the lights minimizes disruption to the patient's circadian rhythm. Background noise (B) and silencing alarms (C) may not always be feasible, and unnecessary analgesics (D) could interfere with sleep.
A post-anesthesia care unit nurse is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?
- A. Arterial blood gases
- B. Urinary output
- C. Chest tube drainage
- D. Pain level
Correct Answer: A
Rationale: The correct answer is A: Arterial blood gases. This is the highest priority assessment for a client post-thoracotomy and lobectomy as it helps monitor the client's oxygenation status and acid-base balance, crucial after thoracic surgery. ABGs provide immediate information on the client's respiratory function, detecting any respiratory complications early on. The other options, B: Urinary output, C: Chest tube drainage, and D: Pain level, are important assessments but not as critical as monitoring the client's oxygenation status post-thoracic surgery. Urinary output is important for renal function, chest tube drainage for monitoring for any bleeding or air leakage, and pain level for comfort, but none of these directly assess the client's respiratory status and potential complications.