Nokea
Which of the following assessments should be a priority immediately after nasal surgery?
- A. Assessing the client's pain.
- B. Inspecting for periorbital ecchymosis.
- C. Assessing respiratory status.
- D. Measuring intake and output.
Correct Answer: C
Rationale: Respiratory status is the priority post-nasal surgery due to the risk of airway obstruction from packing or swelling. Pain, ecchymosis, and fluid balance are important but secondary to airway patency.
You may also like to solve these questions
The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring?
- A. Muscle relaxation.
- B. Intake and output.
- C. Widening of the pulse pressure.
- D. Pupil dilation.
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic used to reduce ICP by drawing fluid from brain tissue. Monitoring intake and output is critical to assess its effectiveness and prevent dehydration or electrolyte imbalances. Muscle relaxation, pulse pressure, and pupil dilation are not directly related to mannitol's primary effects.
A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the following outcomes are undesirable? Select all that apply.
- A. Dermatitis.
- B. Bleeding.
- C. Fungal infection.
- D. Flow of adhesive solvent into the stoma.
- E. Partial obstruction of the stoma from skin cement.
Correct Answer: A,B,C,D,E
Rationale: Dermatitis, bleeding, fungal infections, adhesive solvent flow, and partial obstruction are all undesirable as they indicate complications such as skin irritation, trauma, infection, or improper appliance application that can impair stoma function or client health.
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client’s body. Using the “rule of nines,” the nurse would determine that about what percentage of the client’s body surface has been burned?
- A. 18%.
- B. 27%.
- C. 45%.
- D. 64%.
Correct Answer: C
Rationale: According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.
The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PCO2 62; PO2 70; HCO3 34. The nurse should:
- A. Apply a 100% non-rebreather mask.
- B. Assess the vital signs.
- C. Reposition the client.
- D. Prepare for intubation.
Correct Answer: B
Rationale: The ABG shows compensated respiratory acidosis (normal pH, high PCO2, high HCO3) with mild hypoxemia (PO2 70). Assessing vital signs evaluates stability before escalating care. A non-rebreather mask or intubation is premature. Repositioning may help but is less urgent.
The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify?
- A. Diabetes
- B. Age
- C. Exercise level
- D. Dietary preferences
Correct Answer: B
Rationale: Age is a non-modifiable risk factor for atherosclerosis, as the risk increases with advancing age due to cumulative vascular changes. Diabetes, exercise level, and dietary preferences can be managed or modified to reduce risk, making age the correct answer.