Nokea
Which of the following nursing actions is appropriate when a patient returns to his or her room after a bronchoscopy?
- A. Order a meal because the patient has been nil per os (NPO) for 8 hours.
- B. Encourage fluids to flush dye from the patient’s system.
- C. Monitor the patient for return to consciousness.
- D. Check for a gag reflex before allowing the patient to drink.
Correct Answer: D
Rationale: The correct answer is D - Check for a gag reflex before allowing the patient to drink. This is important after a bronchoscopy to prevent aspiration. Step 1: Assessing gag reflex ensures the patient can protect their airway. Step 2: Aspiration risk is high post-bronchoscopy due to sedation and possible throat numbness. Step 3: Allowing fluids without confirming gag reflex can lead to aspiration pneumonia. Other choices are incorrect. A: Ordering a meal immediately is inappropriate after NPO period. B: Encouraging fluids without assessing gag reflex may lead to aspiration. C: Monitoring consciousness is important but not directly related to post-bronchoscopy care.
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Before administering a food feeding the nurse knows to perform which of the following assessments/
- A. The GI tract, including bowel sounds, last BM, and distention
- B. The client’s neurologic status, especially the gag reflex
- C. The amount of air in the stomach
- D. That the formula is used directly from the refrigerator
Correct Answer: A
Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
- A. insulin.
- B. poatassium chloride.
- C. furosemide (Lasix)
- D. vasopressin (Pitressin).
Correct Answer: D
Rationale: The correct answer is D: vasopressin (Pitressin). In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), which leads to excessive urination and thirst. Vasopressin is a synthetic form of ADH that helps regulate water balance by reducing urine output. Therefore, administering vasopressin would help manage the symptoms of diabetes insipidus. Insulin (A) is used for diabetes mellitus, not diabetes insipidus. Potassium chloride (B) is used to correct potassium imbalances, not specific to diabetes insipidus. Furosemide (Lasix) (C) is a diuretic that increases urine output, which would worsen the symptoms of diabetes insipidus.
Which of the ff would describe the discomfort experienced by a client with a tension headache?
- A. A heavy feeling over the frontal region and sensitivity to light
- B. Pressure or steady constriction on both sides of the head
- C. Headache and temporary unilateral paralysis
- D. Vague headache, especially peri orbital
Correct Answer: B
Rationale: The correct answer is B because tension headaches typically present as a feeling of pressure or steady constriction on both sides of the head. This is due to muscle tension in the head and neck. Choice A is incorrect as sensitivity to light is more characteristic of migraines. Choice C is incorrect as unilateral paralysis is not typically associated with tension headaches. Choice D is incorrect as vague headache especially peri orbital is not a common symptom of tension headaches. Therefore, the best description of discomfort experienced by a client with a tension headache is the pressure or steady constriction on both sides of the head.
Which of the following is the most numerous type of white blood cell (WBC)?
- A. Neutrophil
- B. Basophil
- C. Eosinophil
- D. Lymphocyte
Correct Answer: A
Rationale: The correct answer is A: Neutrophil. Neutrophils are the most numerous type of WBC, typically comprising 50-70% of total WBC count. They are key players in the body's immune response, phagocytizing pathogens. Basophils, eosinophils, and lymphocytes are less numerous than neutrophils. Basophils are involved in allergic reactions, eosinophils combat parasitic infections, and lymphocytes play a critical role in adaptive immunity. However, in terms of sheer numbers, neutrophils outnumber the other types of WBC.
A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
- A. to increase bladder atony
- B. to maintain patency of the foley
- C. to remove blood clots from the bladder catheter
- D. to lower the specific gravity of the urine
Correct Answer: B
Rationale: Rationale:
B is correct because cystoclisis is the process of maintaining patency of a foley catheter by irrigating it with a sterile solution. This prevents blockages and promotes proper drainage.
A, C, and D are incorrect because cystoclisis is not related to increasing bladder atony, removing blood clots, or altering urine specific gravity.