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 action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?
- A. Teach the patient to rest the brain by avoiding new activities.
- B. Teach that 'chemo-brain' is a short-term effect of chemotherapy.
- C. Report patient symptoms immediately to the health care provider.
- D. Suggest use of a daily planner and encourage adequate rest and sleep.
Correct Answer: D
Rationale: Chemo-brain foggy focus is common; planners and rest help manage, not cure. Resting fully stalls life; it's not always short-term can linger. No emergency it's expected. Nurses in oncology offer this tools and sleep ease the mental muck, supporting function.
The nurse knows which of the following is the most common problem for a client with valvular heart disease?
- A. Altered body image
- B. Difficulty coping
- C. Bradycardia
- D. Decreased cardiac output
Correct Answer: D
Rationale: Valvular disease stenosis or regurgitation slashes flow; decreased cardiac output reigns as pump falters, driving fatigue and dyspnea, the top issue. Body image or coping lag; bradycardia's rare. Nurses peg output drop, targeting meds or surgery, a core fight in this valve-wrecked heart.
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.
What is the highest likelihood that a doctor acquires HIV from a needlestick injury from an HIV pt?
- A. 0.30%
- B. 2%
- C. 5%
- D. 10%
Correct Answer: A
Rationale: HIV needlestick 0.3% odds, not 2-30's wild leaps. Nurses glove up, a chronic prick stat.
According to Johnson and Chang (2014), people living with chronic illness are more likely than the general population to:
- A. Have significantly reduced activity and subsequent loss of independence
- B. Be required to see their doctor more regularly
- C. Experience periods of hospitalisation as a consequence of acute flare-ups of their underlying chronic disease
- D. Stay home and reduce their activity and social interactions
Correct Answer: A
Rationale: Chronic illness curbs activity arthritis, COPD slash mobility, stealing independence, a standout hit over frequent doctor visits, hospital stays from flares, or self-imposed isolation. Those ripple too, but reduced function's the core burden, reshaping daily life. Nurses prioritize this, boosting support, a chronic truth where physical loss leads.