Nokea
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
- A. Wilma places 2 fingers between the tie and neck
- B. The tracheotomy can be pulled slightly away from the neck
- C. James’ neck veins are not engorged
- D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process
Correct Answer: A
Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow.
Incorrect choices:
B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties.
C: James’ neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties.
D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.
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Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse’s analysis are:
- A. Rise in blood pressure and heart rate
- B. Rise in blood pressure and drop in heart rate
- C. Drop in blood pressure and rise in heart rate
- D. none of the above
Correct Answer: C
Rationale: The correct answer is C: Drop in blood pressure and rise in heart rate. After a splenectomy, the client is at risk for orthostatic hypotension due to decreased blood volume. A drop in blood pressure and a compensatory rise in heart rate are common orthostatic changes. This occurs because the body tries to maintain perfusion to vital organs. A rise in blood pressure and heart rate (Choice A) would not align with orthostatic changes. A rise in blood pressure and drop in heart rate (Choice B) is contradictory to the body's compensatory response to maintain perfusion. Therefore, the most supportive vital sign values for abnormal orthostatic changes in this client would be a drop in blood pressure and a rise in heart rate.
A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?
- A. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin
- B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ
- C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found
- D. Alteration in the size, shape, and organization of differentiated cells
Correct Answer: D
Rationale: The correct answer is D because dysplasia refers to the alteration in the size, shape, and organization of differentiated cells. Dysplasia is an abnormal growth or development of cells that can be a precursor to cancer. It is characterized by changes in cell size, shape, and organization, which can be seen in Papanicolaou tests.
Choice A is incorrect because it describes an undifferentiated tumor, not dysplasia. Choice B is incorrect as it describes hyperplasia, not dysplasia. Choice C is incorrect as it refers to metaplasia, not dysplasia.
In summary, dysplasia is specifically about the abnormal changes in the appearance and organization of differentiated cells, making choice D the correct definition.
Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
- A. Risk nursing diagnosis
- B. Actual nursing diagnosis
- C. Possible nursing diagnosis
- D. Wellness diagnosis
Correct Answer: B
Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, such as signs and symptoms exhibited by the patient. This helps in identifying the specific health issues that the patient is currently experiencing. In contrast, a risk nursing diagnosis is focused on potential health problems that the patient may develop in the future. Possible nursing diagnosis involves uncertain or unclear health issues that require further assessment. Wellness diagnosis is aimed at enhancing health and promoting well-being, rather than addressing existing health problems. Therefore, the presence of major defining characteristics is crucial in confirming an actual nursing diagnosis.
Which of the following is not a criterion for a valid informed consent that a nurse should identify?
- A. freely given
- B. with coercion
- C. has an explanation of procedures
- D. describes the alternatives
Correct Answer: B
Rationale: The correct answer is B: with coercion. Informed consent must be freely given without any form of coercion to ensure the individual's autonomy and decision-making capacity. Coercion can lead to involuntary consent, undermining the principle of respect for autonomy. Choices A, C, and D are all criteria for valid informed consent. Choice A ensures the individual is voluntarily agreeing without any external pressure. Choice C ensures the individual understands the procedures involved, promoting transparency. Choice D ensures the individual is aware of alternative options, allowing for an informed decision-making process.
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
- A. Cough as the cuff is being deflated
- B. Take a deep breath as the nurse deflates the cuff
- C. Hold the breath as the cuff is being re-inflated
- D. Exhale deeply as the nurse re-inflates the cuff
Correct Answer: B
Rationale: The correct answer is B: Take a deep breath as the nurse deflates the cuff. This is the correct choice because asking the client to take a deep breath while the cuff is deflated helps prevent aspiration of secretions into the lower airway. When the cuff is deflated, the tracheostomy tube provides a direct pathway for secretions to travel upwards, and taking a deep breath facilitates the movement of secretions out of the trachea.
Choice A (Cough as the cuff is being deflated) is incorrect because coughing while the cuff is being deflated can increase the risk of aspiration as secretions may be forced into the lower airway.
Choice C (Hold the breath as the cuff is being re-inflated) is incorrect as holding the breath while the cuff is being re-inflated can hinder the clearance of secretions from the trachea.
Choice D (Exhale deeply as the nurse re-inflates the cuff) is incorrect