Nokea
When developing a teaching plan for a patient, what should the nurse recognize?
- A. Frustration will enhance the patient’s desire to learn
- B. Only formal teaching plans have been found to be effective
- C. The patient’s previous educational experiences do not influence his learning
- D. The patient must accept responsibility for compliance with his therapeutic regimen
Correct Answer: D
Rationale: Patient responsibility is essential for adherence to therapeutic regimens.
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A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Check the tubing connections for leaks.
- B. Check the suction control outlet on the wall.
- C. Clamp the chest tube.
- D. Continue to monitor the client's respiratory status.
Correct Answer: A
Rationale: The correct answer is A: Check the tubing connections for leaks.
1. Slow, steady bubbling in the suction control chamber indicates an air leak in the system.
2. Checking the tubing connections for leaks is the appropriate action to identify and fix the issue.
3. This helps maintain the integrity of the closed chest drainage system and prevent complications.
Other choices are incorrect:
B: Checking the suction control outlet on the wall is not necessary as the issue is likely within the tubing system.
C: Clamping the chest tube could lead to tension pneumothorax and is not recommended unless ordered by a physician.
D: Continuing to monitor the client's respiratory status does not address the underlying problem of the air leak.
Mrs. Williams asks what “presbyopia†means. The best response would be that Mrs. Williams
- A. is 'farsighted' and can see well at a distance, but her near vision is poor
- B. is 'nearsighted' and can see well when objects are close but cannot see well at a distance
- C. has distorted vision which is caused by a curvature in the eye
- D. has difficulty seeing objects that are very close because her lens is less elastic
Correct Answer: D
Rationale: Presbyopia results from decreased elasticity of the eye's lens, impairing the ability to focus on nearby objects, typically occurring with age.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. The client who has been NPO since midnight for endoscopy
- B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL
- C. The client who has end-stage renal failure and is scheduled for dialysis today
- D. The client who has gastroenteritis and is febrile
Correct Answer: D
Rationale: Step 1: The client with gastroenteritis is at risk for fluid volume deficit due to vomiting and diarrhea, leading to loss of fluids.
Step 2: Febrile state increases fluid loss through sweating.
Step 3: Combining gastroenteritis and fever exacerbates fluid loss, making this client at high risk.
Step 4: Clients A, B, and C do not have immediate factors contributing to fluid volume deficit as evident from their conditions.
Summary: Client D is at risk due to gastroenteritis and fever causing significant fluid loss. Clients A, B, and C do not have conditions directly leading to fluid deficit.
To improve Mr. Puff’s breathing pattern, the nurse can
- A. Encourage coughing and deep breathing
- B. Provide nasal O₂ at 6 L/min
- C. Sit him in a chair
- D. Teach him pursed-lip breathing
Correct Answer: D
Rationale: Pursed-lip breathing improves oxygenation and reduces shortness of breath.
A client is scheduled for a pneumonectomy in the morning. The client has had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
- A. providing opportunities for questions and talking about the client's concerns.
- B. providing distractions such as reading or watching television.
- C. assuring the client that everything will be all right.
- D. reminding the client that the surgery is not as extensive as the client's past surgery.
Correct Answer: A
Rationale: Providing an opportunity for an open discussion will help to clarify any misunderstandings about the surgery and gives the client a chance to verbalize any concerns about the surgery. Distractions will not alleviate the client's preoperative anxiety; it denies the anxiety the client is experiencing. Giving false assurance is not appropriate and it denies that anxiety is a normal response to the threat of surgery. Psychological responses are not directly related to the severity of the surgery; they are influenced by the client's experience.