Nokea
While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. Which of the following should be the nurse's first action?
- A. Lower the head of the bed and call the physician.
- B. Prepare an aspiration tray.
- C. Mark the area with a skin pencil at the outer perippliess to the crackling.
- D. Turn off the suction of the chest drainage system.
Correct Answer: C
Rationale: The crackling sensation indicates subcutaneous emphysema. Marking the area monitors its spread, guiding further action. Lowering the bed, preparing aspiration, or turning off suction are not immediate priorities.
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A 58-year-old male is going to have chemotherapy for lung cancer. He asks the nurse how the chemotherapeutic drugs will work. The most accurate explanation the nurse can give is which of the following?
- A. Immunotherapy affects all rapidly dividing cells.
- B. The molecular structure of the DNA is altered.
- C. Cancer cells are susceptible to drug toxins.
- D. Chemotherapy encourages cancer cells to divide.
Correct Answer: B
Rationale: Chemotherapy often works by altering the DNA structure of cancer cells, inhibiting their ability to replicate and leading to cell death.
What should the nurse teach a client about how to avoid the dumping syndrome? Select all that apply.
- A. Consume three regularly-spaced meals per day.
- B. Eat a diet with high carbohydrate foods with each meal.
- C. Reduce fluids with meals, but take them between meals.
- D. Obtain adequate amounts of protein and fat in each meal.
- E. Eat in a relaxing environment.
Correct Answer: C,D,E
Rationale: To avoid dumping syndrome, clients should reduce fluids with meals, ensure adequate protein and fat, and eat in a relaxing environment. Three meals a day and high-carbohydrate foods can exacerbate symptoms.
The nurse will anticipate which of the following problems that can result for the older adult undergoing abdominal surgery?
- A. Uncrossed scarring.
- B. Decreased melanin and melanocytes.
- C. Decreased healing.
- D. Increased immunocompetence.
Correct Answer: C
Rationale: Older adults have slower wound healing due to reduced collagen synthesis and cellular turnover, increasing the risk of delayed recovery post-surgery.
A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation?
- A. The client has not been including enough fiber in his diet.
- B. The client needs to increase his daily exercise.
- C. The client is experiencing an adverse effect of the aluminum hydroxide.
- D. The client has developed a gastrointestinal obstruction.
Correct Answer: C
Rationale: Aluminum hydroxide is known to cause constipation as a common adverse effect, especially with frequent dosing. The other options are less likely given the direct association with the medication.
A client with diabetes mellitus comes to the clinic for a regular 3-month follow-up appointment. The nurse notes several small bandages covering cuts on the client's hands. The client says, 'I'm so clumsy. I'm always cutting my finger cooking or burning myself on the iron.' Which of the following responses by the nurse would be most appropriate?
- A. Soak small wounds in isopropyl alcohol.'
- B. Keep all cuts clean and covered.'
- C. Why don't you have your children do the cooking and ironing?'
- D. You really should be fine as long as you take your daily medication.'
Correct Answer: B
Rationale: Keeping cuts clean and covered prevents infection, a significant risk in diabetes due to poor wound healing.