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Which postoperative complication results from saliva, mucus, vomitus, or blood making its way into the lungs as a result of difficulty in swallowing or a client’s inability to rid himself/herself of oral secretions?
- A. Aspiration
- B. Hypoxia
- C. Shock
- D. Hemorrhage
Correct Answer: A
Rationale: The correct answer is A because aspiration occurs when foreign material enters the lungs.
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When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to:
- A. Avoid smoking near the client.
- B. Turn off oxygen during meals.
- C. Adjust the liter flow to 10 as needed.
- D. Remind the client to keep mouth closed.
Correct Answer: A
Rationale: Smoking near oxygen poses a fire hazard and exacerbates respiratory issues.
The nurse is caring for a client with trigeminal neuralgia. To assist the client with nutrition needs, the nurse should:
- A. Offer small meals of high calorie soft food.
- B. Assist the client to sit in a chair for meals.
- C. Provide additional servings of fruits and raw vegetables.
- D. Encourage the client to eat fish, liver and chicken.
Correct Answer: A
Rationale: Soft foods minimize facial muscle movement, reducing pain.
Which factors predispose a client to hypoxia during the immediate postoperative period?
- A. Pooling of secretions in the lungs
- B. Fluid and electrolyte loss
- C. Physical and psychological trauma
- D. Increased mobility
Correct Answer: A
Rationale: The correct answer is A because pooled secretions can obstruct airways, leading to hypoxia.
When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct Answer: A
Rationale: Step 1: Encouraging the client and family to be active partners promotes safety by involving them in care decisions.
Step 2: This empowers the client to voice concerns and preferences, enhancing their safety.
Step 3: Monitoring hand hygiene (B) is important but doesn't directly involve the client's active participation.
Step 4: Offering family to stay (C) is supportive but doesn't directly engage the client in promoting their own safety.
Step 5: Advising to wear armband (D) is a procedural measure, not a collaborative safety-promoting action.
What is your most appropriate response to Mr. Brown suspecting tuberculosis?
- A. Unless you have symptoms you could not have tuberculosis
- B. Have you ever had a skin test for tuberculosis?
- C. A routine chest x-ray will determine if you have tuberculosis
- D. Your neighbor could not infect you if he has been following his treatment regimen
Correct Answer: B
Rationale: A tuberculin skin test detects latent TB infection, even without symptoms.