Nokea
Why is caution needed when asking family members to interpret?
- A. Family members may misinterpret or omit critical information.
- B. It saves time and resources.
- C. It promotes family involvement.
- D. It ensures confidentiality.
Correct Answer: A
Rationale: Family members may unintentionally alter messages, leading to potential misunderstandings or errors in care.
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During a call to the on-call physician about a client who had a hysterectomy 2 days ago & has unrelieved pain from prescribed narcotic medication, which statement is part of the SBAR format for communication?
- A. I suggest ordering a different pain medication.
- B. This client has allergies to morphine & codeine.
- C. Dr. Smith does not prefer nonsteroidal anti-inflammatory meds.
- D. The client had a vaginal hysterectomy 2 days ago.
Correct Answer: B
Rationale: The correct answer is B because it provides relevant information regarding the client's allergies to morphine and codeine, which is crucial for the physician to know when considering alternative pain medication options. This aligns with the "Background" component of the SBAR format, which includes pertinent patient history.
Choice A is incorrect because it jumps to a solution without providing necessary background information. Choice C is irrelevant to the current situation as it does not address the client's pain management issue. Choice D is also incorrect as it only provides historical information about the type of hysterectomy performed, which is not directly related to the client's current pain management concern.
What is the primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team?
- A. Avoiding any type of injury to the patient
- B. Maintaining a clean environment for the patient
- C. Providing for patient comfort and sense of well-being
- D. Preventing breaks in aseptic technique by the sterile members of the team
Correct Answer: D
Rationale: The circulating nurse ensures aseptic practices are maintained throughout the surgical procedure.
Lack of bubbling in the suction control chamber indicates
- A. Excessive negative pressure (suction)
- B. A leak somewhere in the drainage system, as within the patient
- C. A kink or plug in the drainage tubing
- D. The patient’s lung has reexpanded
Correct Answer: D
Rationale: Reexpanded lungs stop air leakage into the drainage system.
After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
- B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
Correct Answer: C
Rationale: Step 1: Wheezes indicate narrowing of the airways, typically seen in conditions like asthma.
Step 2: Inhaled bronchodilators help dilate the airways, relieving wheezing and improving breathing.
Step 3: Hence, administering an inhaled bronchodilator is the correct intervention for wheezes.
Summary:
A: Increasing oxygen flow does not directly address the issue of wheezes.
B: Encouraging coughing does not address the narrowing of airways seen with wheezes.
D: Deep breathing does not specifically target the narrowing of airways associated with wheezes.
A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I can sleep on my side as long as I use a pillow between my legs.
- C. I will avoid bending at the waist to pick things up.
- D. I can bend down to tie my shoes after 2 weeks.
Correct Answer: D
Rationale: The correct answer is D because bending down to tie shoes after only 2 weeks post total hip replacement can put strain on the hip joint and increase the risk of dislocation. The client should avoid bending past 90 degrees to protect the new hip joint. Choices A, B, and C are all correct statements as they promote hip joint protection and reduce the risk of complications.