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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 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.
Which client(s) would be best to assign to an experienced nurse in an ambulatory eye surgery center? (Choose all that apply.)
- A. A client who needs post-operative instructions for cataract surgery.
- B. A client who needs an eye-pad and a metal shield applied.
- C. A client who needs home health referral for dressing changes and eye drops.
- D. A client who needs teaching about self-administration of eye drops.
Correct Answer: A
Rationale: Clients requiring complex post-operative instructions, such as those for cataract surgery, benefit most from the expertise of an experienced nurse.
12. When discussing herbal therapy with a patient, what should the nurse advise the patient?
- A. Preparations should be purchased only from reputable manufacturers.
- B. Herbs rarely cause harm or side effects because they are natural plants.
- C. Herbs are safe and there are no known contraindications to the use of herbal therapy.
- D. Most herbal preparations have been clinically tested for safety and efficacy before marketing.
Correct Answer: A
Rationale: Option A emphasizes the importance of purchasing herbal preparations from reputable sources to ensure quality and safety, which is crucial advice for patients.
What should govern the nurse’s actions regarding Mr. West rubbing Mrs. West’s calf?
- A. Touch is an important method of communication
- B. It is important to involve family members in patient care
- C. Massage increases circulation, therefore reducing tenderness
- D. A thrombus becomes an embolus when dislodged
Correct Answer: D
Rationale: Massaging the leg could dislodge a clot, leading to complications.
While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
- A. It decreases the client's level of anxiety.
- B. It facilitates the client's deep breathing.
- C. It enhances the client's ability to sleep.
- D. It reduces the client's blood pressure.
Correct Answer: B
Rationale: The correct answer is B because facilitating the client's deep breathing is crucial post-CABG surgery to prevent complications such as atelectasis and pneumonia. Deep breathing helps improve lung expansion and oxygenation, promoting healing and preventing respiratory issues.
A: While decreasing anxiety is important for overall well-being, it is not directly related to the client's recovery post-CABG surgery.
C: Enhancing sleep is beneficial for healing, but it is not as critical as ensuring proper respiratory function in the immediate postoperative period.
D: While reducing blood pressure may be desirable in some cases, it is not the most important effect to focus on post-CABG surgery; maintaining adequate oxygenation through deep breathing takes precedence.