Nokea
When admitting a client with active tuberculosis to a room on a medical-surgical unit, which of the following room assignments should the nurse make?
- A. A room with air exhaust directly to the outdoor environment
- B. A room with another nonsurgical client
- C. A room in the ICU
- D. A room that is within view of the nurses' station
Correct Answer: A
Rationale: The correct answer is A: a room with air exhaust directly to the outdoor environment. This is to prevent the spread of tuberculosis to other patients and healthcare workers. Tuberculosis is an airborne disease, so proper ventilation is crucial. Choice B is incorrect as placing the client with another nonsurgical client may increase the risk of transmission. Choice C is not ideal as the ICU may have other vulnerable patients. Choice D is also incorrect as the proximity to the nurses' station does not address the need for proper ventilation to prevent the spread of tuberculosis.
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A female postoperative client has returned to the Unit following a pneumonectomy. In assessing the client's incision, twenty-four hours postoperatively, the nurse notices fresh blood on the dressing. The nurse should first:
- A. reinforce the dressing.
- B. continue to monitor the dressing.
- C. notify the physician.
- D. note the time and amount of blood.
Correct Answer: C
Rationale: The dressing should not be reinforced without notifying the physician. The physician may decide to reinforce the dressing after assessing the amount of bleeding. Blood on the dressing is unusual, which should alert the nurse to do more than monitor the dressing. The physician should be notified immediately. If the bleeding persists, the client may need to return to surgery. The time and amount of blood needs to be recorded, but only after the physician is notified.
Mrs. Dailey tells the nurse that she uses eyedrops which make her pupils get small. Which of the following drugs would produce this effect?
- A. Epinephrine (Adrenalin)
- B. Acetazolamide (Diamox)
- C. Atropine
- D. Pilocarpine
Correct Answer: D
Rationale: Pilocarpine is a miotic agent that constricts the pupil, commonly used in treating glaucoma by improving aqueous humor outflow.
For a patient with osteogenic sarcoma, you would be particularly vigilant for elevations in which laboratory value?
- A. Sodium.
- B. Calcium.
- C. Potassium.
- D. Hematocrit.
Correct Answer: B
Rationale: Elevated calcium levels are commonly associated with osteogenic sarcoma due to bone destruction and release of calcium into the bloodstream.
What type of procedural information should be given to a patient in preparation for ambulatory surgery (select all that apply)?
- A. How pain will be controlled
- B. Any fluid and food restrictions
- C. Characteristics of monitoring equipment
- D. What odors and sensations may be experienced, Technique and practice of coughing and deep breathing, if appropriate
Correct Answer: D
Rationale: Providing comprehensive procedural information prepares the patient physically and mentally for surgery.
A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
- A. Kussmaul respirations
- B. Apneustic respirations
- C. Cheyne-Stokes respirations
- D. Stridor
Correct Answer: C
Rationale: The correct answer is C: Cheyne-Stokes respirations. This breathing pattern is characterized by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations (A) are deep and rapid breathing associated with metabolic acidosis. Apneustic respirations (B) are characterized by prolonged inhalation and short, insufficient exhalation. Stridor (D) is a high-pitched, noisy breathing sound caused by obstructed air flow in the upper airway, not associated with the described breathing pattern.