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Why would a Heimlich maneuver be performed on a client?
- A. To increase the absorption of the prescribed medication
- B. To clear the airway if the client cannot speak or breathe after swallowing food
- C. To reduce the potential for injuries as a result of falls
- D. To maintain extremities in proper anatomic position CARING FOR CLIENT WITH HEAD AND SPINAL CORD TRAUMA
Correct Answer: B
Rationale: The Heimlich maneuver is performed to clear the airway if a client is choking and cannot speak or breathe after swallowing food. Step 1: Assess the situation and confirm airway obstruction. Step 2: Stand behind the client, wrap your arms around their waist, and deliver upward abdominal thrusts. Step 3: Repeat thrusts until the object is dislodged. Other choices are incorrect as they do not address airway obstruction. A: Increasing medication absorption is not a purpose of the Heimlich maneuver. C: Preventing falls and D: Maintaining extremities in proper position are not related to choking emergencies.
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The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
- A. To gather data about a specific and current health problem.
- B. To identify life-threatening problems that require immediate attention.
- C. To compare and contrast current health status to baseline data.
- D. To establish a database to identify problems and strengths.
Correct Answer: D
Rationale: The correct answer is D: To establish a database to identify problems and strengths. This initial assessment is crucial for gathering comprehensive information about the client's health status, including past medical history, current health problems, and potential risk factors. By establishing a database, the nurse can identify both existing health issues that need to be addressed and strengths that can be built upon for effective care planning. This assessment serves as the foundation for developing an individualized care plan and monitoring the client's progress throughout their hospital stay.
Explanation of other options:
A: To gather data about a specific and current health problem - While this may be part of the assessment process, the main purpose is broader in scope to establish a comprehensive database.
B: To identify life-threatening problems that require immediate attention - While identifying urgent issues is important, the initial assessment is not solely focused on life-threatening problems.
C: To compare and contrast current health status to baseline data - While comparing to baseline data is important for tracking changes, the primary purpose
Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?
- A. “ Right after the operation, I will wear the pneumatic compression device while sitting on the chair.”
- B. “I will not eat anything after 12 pm the night befire my operation, but I sure can drink.”
- C. “The skin preparation site is longer and wider than the actual incision site.”
- D. “I will need to sign the consent from after I get to the operating table.”
Correct Answer: B
Rationale: The correct answer is B. Mr. Sy's statement indicates he understands the pre-operative fasting instructions, which is crucial to prevent aspiration during surgery. Not eating after midnight reduces the risk of complications.
A: Incorrect. Wearing a pneumatic compression device post-surgery is important, but this statement does not demonstrate understanding of pre-surgery preparations.
C: Incorrect. Knowing the skin preparation site size does not indicate understanding of the surgery process.
D: Incorrect. Signing the consent form at the operating table may indicate lack of understanding of the consent process and timing.
In summary, choice B is correct as it shows Mr. Sy's awareness of the fasting requirement before surgery, which is crucial for a safe operation.
Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?
- A. Cellular dehydration and potassium
- B. Hypoglycemia and hypovolemia
- C. Potassium excess and CHF
- D. Circulatory overload and hypoglycemia SITUATION: In the recall of the fluids and electrolytes, the nurse should be able to understand the calculations and other conditions related to loss or retention.
Correct Answer: D
Rationale: Rationale:
1. Rapid infusion of hyperalimentation solutions can lead to circulatory overload due to increased fluid volume in the circulatory system.
2. Circulatory overload can result in symptoms such as hypertension, tachycardia, and edema.
3. Hypoglycemia can occur as a result of excess insulin release due to the sudden increase in glucose from the hyperalimentation solution.
Summary:
A. Cellular dehydration and potassium: Incorrect. Rapid infusion would lead to fluid overload, not dehydration.
B. Hypoglycemia and hypovolemia: Incorrect. Hypovolemia is unlikely with rapid infusion, and hypoglycemia is a possible side effect.
C. Potassium excess and CHF: Incorrect. Rapid infusion may cause circulatory overload, not CHF, and potassium excess is not a common side effect.
D. Circulatory overload and hypoglycemia: Correct. These are the most likely side effects of rapid
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
- A. Lungs
- B. Liver
- C. Kidneys
- D. Heart
Correct Answer: D
Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications.
Summary:
A: Lungs - Not directly affected by potassium levels.
B: Liver - Not directly affected by potassium levels.
C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.
A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?
- A. Individualize the care plan only according to the patient’s needs.
- B. Request that the son leave at bedtime, so the patient can rest.
- C. Suggest that a female member of the family stay with the patient.
- D. Involve the son in the plan of care as much as possible.
Correct Answer: D
Rationale: The correct answer is D: Involve the son in the plan of care as much as possible. This is important for several reasons. Firstly, involving the son promotes family-centered care, which can improve patient outcomes. Secondly, the son may provide valuable insights into the patient's preferences and needs. Thirdly, it can help reduce the patient's confusion by providing familiar support. Option A is incorrect as it disregards the potential benefits of involving family members. Option B is incorrect as it focuses on the patient's rest without considering the emotional support the son may provide. Option C is incorrect as it assumes the gender of the family member matters more than their relationship to the patient.