Nokea
Which nursing action should be included in the plan of care for a client returning to the surgical unit following a left modified radical mastectomy with dissection of axillary lymph nodes?
- A. Obtain permanent breast prosthesis before the patient is discharged from the hospital
- B. Teach the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes
- C. Place a pink bracelet on the client warning against venipunctures or blood pressures in the left arm
- D. Insist that the patient examine the surgical incision when the initial dressings are removed
Correct Answer: C
Rationale: Mastectomy with axillary dissection risks lymphedema a pink bracelet flags the left arm, barring venipuncture or BP cuffs to prevent swelling, a priority in post-op care. Prosthesis comes later, post-healing. PCA teaching avoids rigid timing PRN's key. Forcing incision checks risks distress, not healing. Nurses lock in this bracelet, safeguarding lymph flow, a must-do in this surgical aftermath to dodge chronic arm woes.
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Which is not a common cause of respiratory symptoms in HIV/AIDS patients?
- A. community acquired bacterial pneumonia
- B. non hodgkins lymphoma
- C. Pulmonary Embolus
- D. CMV
Correct Answer: C
Rationale: Pulmonary embolus isn't HIV's lung usual clots tie to beds, not AIDS' immune dive. Pneumonia, lymphoma, CMV, PCP thrive in CD4's fall; emboli don't care. Nurses chase opportunists first, a chronic breath thief lineup skipping this oddball.
Upon percussion of the midclavicular line from cranial to caudal, you can locate the absolute and relative lung-liver borders. Question: What produces the sound you hear between these two borders?
- A. It is caused by lung tissue
- B. It is caused by liver tissue
- C. It is caused by colon tissue
- D. It is caused by the overlap of lung tissue and liver tissue
Correct Answer: D
Rationale: Lung-liver edge overlap dulls the tap, not pure lung, liver, or colon. Nurses hear this, a chronic border beat.
A nurse is caring for a client who presented to the emergency department with complaints of fatigue, palpitations, and chest pains. Upon assessment, the provider notes an S3 and S4 gallop, weak peripheral pulses, and tachycardia. The provider orders a chest x-ray and echocardiogram, which reveals left ventricular dilation. Which of the following disorder is consistent with these findings?
- A. Cardiac tamponade
- B. Dilated cardiomyopathy
- C. Pericarditis
- D. Restrictive cardiomyopathy
Correct Answer: B
Rationale: Left ventricular dilation with S3, S4, weak pulses, and tachycardia paints dilated cardiomyopathy heart muscle stretches, weakening pump, causing fatigue and palpitations. Tamponade compresses, not dilates. Pericarditis inflames without dilation. Restrictive stiffens, resisting stretch. Nurses tie this to DCM's systolic flop, anticipating meds like ACE inhibitors, a fit for this stretched-out heart.
Within the theory of planned behaviour, what is the term used to indicate the idea that a particular behaviour will either succeed or not?
- A. Attitude
- B. Implementation-intention
- C. Intention
- D. Perceived behavioural control
Correct Answer: D
Rationale: Planned behaviour control belief sways success odds, not liking, plans, or will. Nurses tap this, a chronic confidence key.
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?
- A. The patient ambulates around the room.
- B. The patient's visitors bring in fresh peaches.
- C. The patient cleans with a warm washcloth after having a stool.
- D. The patient uses soap and shampoo to shower every other day.
Correct Answer: B
Rationale: Neutropenia post-chemo drops immunity fresh peaches with thin skins harbor bacteria, a no-no on neutropenic diets. Walking , cleaning post-stool , and mild showers are fine safe self-care. Nurses in oncology reteach this raw fruits are infection traps, a critical miss for this fragile patient.