Nokea
Which of the following food selections would need to be removed from a tray for a client recovering from thyroidectomy?
- A. Fresh apple
- B. V8 juice
- C. Mustard greens
- D. Ice cream
Correct Answer: A
Rationale: The correct answer is a fresh apple. After a thyroidectomy, it is important to avoid hard and crunchy foods like apples due to the proximity of the esophagus to the surgical site. Apples can be difficult to chew and swallow, posing a risk of injury or discomfort to the patient. V8 juice, mustard greens, and ice cream are softer options that would be more suitable for a client recovering from thyroidectomy.
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Which symptom is the client who self-administered an overdose of acetaminophen most likely to exhibit?
- A. Pink frothy sputum
- B. Seizure activity
- C. Jaundiced conjunctiva
- D. Diaphoresis and fever
Correct Answer: C
Rationale: When a client self-administers an overdose of acetaminophen, the liver is primarily affected. Jaundiced conjunctiva, which is yellowing of the eyes, is a common symptom of liver damage. Pink frothy sputum is typically associated with conditions like pulmonary edema, not acetaminophen overdose. Seizure activity is not a common symptom of acetaminophen overdose but can be seen in other toxicities. Diaphoresis and fever are more generalized symptoms and not specific to acetaminophen overdose.
A patient has been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?
- A. Transferring the patient to the shower.
- B. Ambulating the patient for the first time.
- C. Taking the patient's breath sounds.
- D. Educating the patient on monitoring fatigue.
Correct Answer: A
Rationale: The correct answer is to delegate the task of transferring the patient to the shower to a nursing assistant. Nursing assistants are trained to assist with transfers safely, making this task appropriate for delegation. Ambulating the patient for the first time involves assessing the patient's mobility and tolerance, which requires more assessment and monitoring by a nurse, especially in a patient with fibromyalgia and COPD. Taking the patient's breath sounds involves assessing the patient's respiratory status, which is a nursing responsibility due to the need for clinical judgment. Educating the patient on monitoring fatigue involves providing vital information and should be done by the nurse to ensure comprehensive understanding and tailored recommendations.
How can a nurse recognize that a chronic renal failure client's AV shunt is patent?
- A. Absence of a bruit
- B. Presence of a thrill
- C. Blood return from the shunt
- D. Urine output greater than 30 ml/hr
Correct Answer: B
Rationale: The correct assessment to determine the patency of an AV shunt in a chronic renal failure client is the presence of a thrill. A thrill is a vibration or buzzing sensation felt over the shunt site, indicating good blood flow through the shunt. While the presence of a bruit is also important for assessing an AV shunt, a thrill is a more specific indicator of patency. Blood return from the shunt is related to cannulation and not necessarily an indicator of patency. Urine output greater than 30 ml/hr is not directly related to the assessment of an AV shunt's patency.
A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR 42, Cheyne-Stokes respirations. Based on this assessment, the nurse anticipates the client to be in which acid-base balance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: In this scenario, the client is exhibiting Cheyne-Stokes respirations, which are characterized by periods of deep breathing alternating with apnea. This pattern indicates respiratory insufficiency, resulting in an accumulation of carbon dioxide in the blood. The elevated BP and slow heart rate further support the respiratory insufficiency, leading to respiratory acidosis. Therefore, the correct answer is Respiratory acidosis.
Choices B, C, and D are incorrect. Respiratory alkalosis is characterized by decreased carbon dioxide levels in the blood, which is not indicated by the client's presentation. Metabolic acidosis results from conditions such as renal failure or diabetic ketoacidosis and is not the primary imbalance in this case. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels, which are not present in the client's vital signs.
The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
- A. Lifting the affected leg with the palms of the hand
- B. Covering the affected leg with a blanket to avoid chills
- C. Placing plastic over the groin prior to bathing
- D. Elevating the cased leg on two pillows
Correct Answer: B
Rationale: The correct answer is covering the affected leg with a blanket to avoid chills. Covering the leg with a blanket can prevent the evaporation of heat from the new cast, which can lead to skin irritation or discomfort. Lifting the affected leg with the palms of the hand is appropriate as it helps in providing support and prevents unnecessary pressure on the cast. Placing plastic over the groin prior to bathing is also acceptable to protect the area from getting wet. Elevating the cased leg on two pillows helps reduce swelling and promotes circulation, making it a suitable action.