Nokea
When performing a physical examination, what approach is most important for the nurse to use?
- A. A head-to-toe approach to avoid missing an important area
- B. The same systematic, efficient sequence for all examinations
- C. A sequence that is least revealing and embarrassing for the patient
- D. An approach that allows time to collect the nursing history data while performing the examination
Correct Answer: B
Rationale: The correct answer is 'The same systematic, efficient sequence for all examinations.' Consistency ensures thoroughness and reduces the likelihood of missing critical details.
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An inflammatory bowel disorder in which the patient develops abdominal pain, bloody diarrhea, tenesmus (feeling of incomplete defecation), and weight loss is
- A. Crohn's disease.
- B. Diverticulitis.
- C. Ulcerative colitis.
- D. Appendicitis.
Correct Answer: C
Rationale: Ulcerative colitis typically presents with these symptoms.
What complication can result from tracheal suctioning?
- A. Acute hypoxemia
- B. Gastric dilatation
- C. Hypervolemic shock
- D. Epiglottitis
Correct Answer: A
Rationale: Suctioning temporarily reduces oxygen levels, necessitating careful monitoring.
A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?
- A. Prevent aspiration.
- B. Ensure adequate nutrition.
- C. Promote oral hygiene.
- D. Relieve the client's pain.
Correct Answer: A
Rationale: The correct answer is A: Prevent aspiration. This is the priority because with intermaxillary fixation, the client is unable to open their mouth, increasing the risk of aspiration. Aspiration can lead to serious complications, such as pneumonia. Ensuring the client's airway is clear and they are able to breathe properly should be the top priority.
Summary:
- B: Ensuring adequate nutrition can be important, but preventing aspiration takes precedence.
- C: Promoting oral hygiene is important but not as urgent as preventing aspiration.
- D: Relieving the client's pain is essential, but ensuring their safety from aspiration is the priority.
What instruction should the nurse give a client with glaucoma?
- A. Avoid going outdoors in the daylight
- B. Avoid getting up too quickly
- C. Avoid heavy lifting
- D. Use cough syrups containing atropine
Correct Answer: C
Rationale: Heavy lifting can increase intraocular pressure, exacerbating glaucoma.
What does the nurse give priority to assessing immediately following Mr. Singer’s total laryngectomy?
- A. Elimination patterns
- B. Level of pain
- C. Gag reflex
- D. Respiratory status
Correct Answer: D
Rationale: Respiratory status is critical due to the altered airway anatomy.