Nokea
Which of the following instructions should be included in the pre-op teaching of a client scheduled for a transphenoidal hypophysectomy for the removal of a pituitary tumor?
- A. It will be necessary to shave some of your hair.
- B. It will be important for you to cough and deep breathe after the surgery.
- C. You will need to lie supine for 24 hours after surgery.
- D. You will not be able to brush your teeth for at least a week after surgery.
Correct Answer: D
Rationale: Post-transphenoidal hypophysectomy, clients avoid brushing teeth for about a week to prevent disruption of the surgical site in the nasal cavity.
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The spouse of a client who had an angioplasty following a heart attack says to the nurse, 'What is an angioplasty? It sounds like plastic surgery. My husband had a heart attack.' What information should be included in the nurse's response?
- A. An angioplasty repairs the heart damage caused by the heart attack.
- B. During an angioplasty, the physician creates a bypass around blocked arteries, increasing the blood flow to the heart muscle.
- C. Angioplasty is a diagnostic procedure to see if there are any blocked coronary arteries.
- D. During an angioplasty, the physician uses a balloon-tipped catheter to open up an artery that is blocked by a clot, thus increasing blood flow to the heart muscle.
Correct Answer: D
Rationale: An angioplasty is the insertion of a balloon-tipped catheter into a coronary artery. The balloon is inflated, opening up the artery and increasing blood flow through the coronary artery to the heart muscle. Angioplasty does not repair heart damage. A left heart cardiac catheterization is the diagnostic procedure that precedes angioplasty. Answer 2 describes a coronary artery bypass graft (CABG) procedure.
The client with cancer of the larynx is admitted to the unit with Acute Respiratory Distress Syndrome. Which nursing diagnosis should receive priority?
- A. Alteration in oxygen perfusion
- B. Alteration in comfort/pain
- C. Alteration in mobility
- D. Alteration in sensory perception
Correct Answer: A
Rationale: Acute Respiratory Distress Syndrome causes severe hypoxemia, making alteration in oxygen perfusion the priority nursing diagnosis to ensure adequate oxygenation. Pain , mobility , and sensory perception are secondary in this life-threatening condition.
A client has returned to the floor from thyroidectomy surgery.
After a client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which of the following actions?
- A. Monitor vital signs every four hours.
- B. Observe for frequent swallowing.
- C. Monitor for signs of respiratory distress every hour.
- D. Position the client in the supine position.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Determine what assessment is being made in each answer choice. (1) assessment is not specific to this surgery (2) assessment, method used to monitor for postoperative hemorrhage in a tonsillectomy client (3) correct-assessment, after surgery, swelling can occur, which causes respiratory distress (4) implementation, head of the bed should be elevated
The physician is assessing renal function in a client with severe pancreatitis. Which laboratory finding would be the best indicator of a problem in this area?
- A. Alkaline phosphatase 20U/L
- B. Hemoglobin 14.6 g/dL
- C. BUN 28 mg/dL
- D. Creatinine 2.3 mg/dL
Correct Answer: D
Rationale: Creatinine is the most specific laboratory test for renal functioning; normal is 0.5-1.5 mg/dL. Answers A and B do not relate to the kidney, so they are incorrect. Answer C can be abnormal with kidney function but is not as specific as the creatinine, so it's incorrect.
The nurse is to administer a nasogastric tube feeding to a client. Which action is essential prior to administering the feeding?
- A. Position the client in supine position.
- B. Aspirate contents from the nasogastric tube and check the pH.
- C. Check the client's vital signs.
- D. Ask the client if she feels full.
Correct Answer: B
Rationale: Aspirating and checking pH confirms nasogastric tube placement in the stomach, preventing aspiration during feeding.