Nokea
Which of the following interventions is appropriate when caring for a client who has lost function of cranial nerve $\mathrm{V}$ on the left side?
- A. Helping the client select foods that are easy to swallow
- B. Speaking to the client on his right side
- C. Applying an eye patch to the left eye
- D. Speaking to the client on his left side
Correct Answer: C
Rationale: Cranial nerve V (trigeminal) loss may impair corneal sensation, increasing risk of eye injury; an eye patch protects the left eye. Swallowing and hearing are unrelated.
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An adult client who had major abdominal surgery is returned to her room on the surgical nursing unit. The postanesthesia nurse reports that the client is awake and has stable vital signs. She has a nasogastric tube in place that is attached to intermittent suction. How should the nurse position the client?
- A. Supine
- B. Semi-sitting
- C. Dorsal recumbent
- D. Prone
Correct Answer: B
Rationale: Semi-sitting facilitates breathing, reduces aspiration risk with a nasogastric tube, and promotes comfort post-abdominal surgery. Supine or dorsal recumbent increases aspiration risk, and prone is contraindicated.
The nurse knows that the MOST reliable client measure for evaluating the desired response diuretic therapy is to
- A. obtain daily weights.
- B. obtain urinalysis.
- C. monitor Na⺠and K⺠levels.
- D. measure intake.
Correct Answer: A
Rationale: effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights
The nurse is caring for a client with pancreatitis experiencing the process of lipolysis of the pancreas. Which assessment would be a priority because of the pathophysiology of lipolysis?
- A. Checking for tetany-like movements
- B. Assessing breath sounds
- C. Obtaining vital signs
- D. Palpating pedal pulses
Correct Answer: A
Rationale: Hypocalcemia is a specific manifestation of clients with pancreatitis and lipolysis, and tetany is a major characteristic of low calcium levels. Answers B, C, and D are all pertinent assessments but are not priorities with the pathophysiology of lipolysis, so they are incorrect.
A client who had a lumbar laminectomy has just returned to the nursing care unit following an uneventful stay in the postanesthesia care unit. How should the nurse position the client?
- A. Supine
- B. Prone
- C. Side-lying
- D. Semi-reclining
Correct Answer: C
Rationale: Side-lying with a pillow between legs maintains spinal alignment post-lumbar laminectomy, reducing strain. Supine or prone may stress the surgical site, and semi-reclining is less ideal.
Which individual is at greatest risk for developing hypertension?
- A. 45 year-old African American attorney
- B. 60 year-old Asian American shop owner
- C. 40 year-old Caucasian nurse
- D. 55 year-old Hispanic teacher
Correct Answer: A
Rationale: 45 year-old African American attorney. The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.