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When the nurse enters the client's room, the nurse perceives that the client is staring straight ahead. Which of the following is the best course of action for the nurse to take next?
- A. Hold an interdisciplinary meeting on the client's behalf promptly.
- B. Consult with psychiatry.
- C. Listen to the client and observe the body language.
- D. Address the client by first name upon entering the room.
Correct Answer: C
Rationale: Listening to the client and observing body language allows the nurse to assess the client's condition and needs, considering macular degeneration may cause the client to appear to stare straight ahead due to central vision loss.
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The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order should the nurse explain the steps to the client?
- A. Breathe in normally through your nose for 2 counts (while counting to yourself, one, two).
- B. Relax your neck and shoulder muscles.
- C. Pucker your lips as if you were going to whistle.
- D. Breathe out slowly through pursed lips for 4 counts (while counting to yourself, one, two, three, four).
Correct Answer: B,A,C,D
Rationale: The correct order for pursed-lip breathing is: relax muscles (B), inhale through nose for 2 counts (A), pucker lips (C), exhale through pursed lips for 4 counts (D). This prolongs exhalation, reducing air trapping.
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: Fluid sequestration into the retroperitoneal space (B) causes significant hypovolemia in pancreatitis, complicating shock management. Intestinal hemorrhage (A), infection (C), and cardiac output (D) are secondary or less common contributors.
What is the main reason desflurane (Suprane) and sevoflurane (Ultane), volatile liquid anesthesia agents, are used for surgical clients who go home the day of surgery?
- A. These agents are better tolerated.
- B. These agents are predictable in their cardiovascular effects.
- C. These agents are nonirritating to the respiratory tract.
- D. These agents are rapidly eliminated.
Correct Answer: D
Rationale: Desflurane and sevoflurane are rapidly eliminated, allowing quicker recovery and discharge, which is ideal for same-day surgery patients.
A client informs the nurse that she is using an herbal therapy while receiving chemotherapy. Which of the following actions should the nurse take?
- A. Determine what substances the client is using and make sure that the physician is aware of all therapies the client is using.
- B. Guide the client in the decision-making process to select either Western or alternative medicine.
- C. Encourage the client to seek alternative modalities that do not require the ingestion of substances.
- D. Recommend that the client stop using the alternative medicines immediately.
Correct Answer: A
Rationale: Determining the herbal therapies used and informing the physician ensures safety, as some herbs can interact with chemotherapy drugs, affecting efficacy or toxicity.
When receiving a client from the postanesthesia care unit after a splenectomy, which should the nurse assess after obtaining vital signs?
- A. Nasogastric drainage.
- B. Urinary catheter.
- C. Dressing.
- D. Need for pain medication.
Correct Answer: C
Rationale: After a splenectomy, the nurse should assess the dressing for signs of bleeding, as the spleen is highly vascular, and postoperative hemorrhage is a risk. Nasogastric drainage, urinary output, and pain are assessed later, but the dressing is the priority to detect complications.