Nokea
Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?
- A. Note subjective data, such as 'My breathing is much improved now.'
- B. Note objective findings, such as decreased respiratory rate and pulse.
- C. Consult with the respiratory therapist to determine effectiveness.
- D. Auscultate the chest for change or clearing of adventitious breath sounds.
Correct Answer: D
Rationale: to assess the effectiveness of suctioning, auscultate the client's chest to determine if the adventitious sounds are cleared and to ensure that the airway is clear of secretions.
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A client preparing for surgery.
Which of the following statements by the client BEST indicates to the nurse an emotional readiness for surgery?
- A. I know the doctor isn't telling me everything, but at this point I can't do anything about it.'
- B. I've never heard of this specialist before. Does he do much work here?'
- C. I'm glad the trapeze is on my bed so I can start working on my exercises as soon as I wake up.'
- D. Can you please check my record to be sure it says I'm diabetic?'
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) indicates feelings of fear and helplessness (2) indicates fear and lack of trust (3) correct-indicates acceptance and a readiness to participate in postoperative care (4) indicates fear that something will be missed
The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which is the proper procedure?
- A. Place the fingertips against the wrist bone.
- B. Place the stethoscope over the apex of the heart.
- C. Place the fingertips against the side of the neck.
- D. Place the fingertips on top of the foot.
Correct Answer: D
Rationale: Pedal pulses are assessed by palpating the dorsalis pedis or posterior tibial arteries on the foot, checking for circulation post-catheterization.
A 26-year-old woman is admitted to the neurosurgery unit for the removal of a cerebellar tumor.
The nurse would expect the patient to make which of the following statements about her symptoms?
- A. I have been having difficulty with my hearing.'
- B. I lose my balance easily.'
- C. I can't tell the difference between a sweet and sour taste.'
- D. It is not easy for me to remember names and faces.'
Correct Answer: B
Rationale: Strategy: Remember physiology. (1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic (2) correct-cerebellum maintains balance (3) CN IX, glossopharyngeal responsible for differentiation of taste (4) not specific symptoms of cerebellum dysfunction
The nurse is caring for a client with a suspected pulmonary embolism.
- A. Which diagnostic Test should the nurse anticipate for a client with a suspected pulmonary embolism?
- B. Chest X-ray.
- C. D-dimer blood Test .
- D. Electrocardiogram (ECG).
- E. Arterial blood gas (ABG).
Correct Answer: B
Rationale: A D-dimer blood Test is a sensitive screening tool for pulmonary embolism, detecting fibrin degradation products from a clot. Chest X-ray and ECG are non-specific, and ABG assesses oxygenation but not the diagnosis directly.
Omeprazole (Prilosec), cimetidine (Tagamet), and Maalox are ordered for an adult. When should the nurse plan to administer these drugs?
- A. Give omeprazole (Prilosec) before meals, cimetidine (Tagamet) with meals, and Maalox after meals.
- B. Give omeprazole (Prilosec) with meals, cimetidine (Tagamet) after meals, and Maalox before meals.
- C. Give omeprazole (Prilosec) after meals, cimetidine (Tagamet) before meals, and Maalox with meals.
- D. Give all of the drugs after meals.
Correct Answer: A
Rationale: Omeprazole (PPI) is taken before meals to inhibit acid production, cimetidine (H2 blocker) with meals to reduce acid during digestion, and Maalox (antacid) after meals to neutralize residual acid.