Nokea
Write a learning goal for the patient taking potassium-wasting diuretics who does not know what foods are high in potassium.
- A. By the end of the session, the patient will identify three potassium-rich foods.
- B. By the end of the session, the patient will demonstrate proper technique for self-administering insulin.
- C. By the end of the session, the patient will list five serious side effects of Coumadin.
- D. By the end of the session, the patient will verbalize understanding of wound care.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?
- A. Production of pink sputum
- B. Tracheal deviation
- C. Drainage greater than 70 mL/hr
- D. Sudden onset of shortness of breath
Correct Answer: B
Rationale: The correct answer is B: Tracheal deviation. Tracheal deviation indicates a tension pneumothorax, a life-threatening emergency that requires immediate intervention to prevent respiratory compromise. The other choices are incorrect because:
A: Production of pink sputum may indicate bleeding but does not require immediate intervention unless severe.
C: Drainage greater than 70 mL/hr may indicate a potential issue with the chest tube, but it does not require immediate intervention unless accompanied by other symptoms.
D: Sudden onset of shortness of breath is concerning but not as immediately life-threatening as tracheal deviation in this context.
The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:
- A. infected.
- B. not healing.
- C. necrotic.
- D. healing.
Correct Answer: D
Rationale: The wound is not infected. An infected wound would contain pus, debris, and exudate. A necrotic wound would appear black or brown. The wound is healing properly. It is filled with red granulated tissue and fragile capillaries. A necrotic wound would appear black or brown. The wound is healing properly. It is filled with red granulated tissue and fragile capillaries.
Why should a nurse use affective touching cautiously?
- A. It may lead to misunderstandings or discomfort.
- B. It involves the contact required for nursing procedures.
- C. It is used therapeutically when a client is lonesome.
- D. It involves the touch used for sensory-deprived clients.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When staging a pressure ulcer, you correctly recognize a stage II ulcer as
- A. Redness, with no break in the skin.
- B. Shallow ulcer with red base.
- C. Dermis involvement with eschar.
- D. Bone visible with no drainage.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?
- A. Notify the operating room of a potential emergency case.
- B. No action is required at this time; this pulsation can be a normal finding in some clients.
- C. Remove the tracheostomy tube and ventilate the client using a bag-valve-mask.
- D. Stay with the client and ask someone else to contact the provider immediately.
Correct Answer: D
Rationale: The correct answer is D: Stay with the client and ask someone else to contact the provider immediately.
Rationale:
1. Pulsation of the tracheostomy tube with heartbeat indicates the tube is very close to a major blood vessel.
2. Immediate provider notification is crucial to prevent potential complications.
3. Removing the tube without professional guidance can lead to severe bleeding and airway compromise.
4. Contacting the provider promptly ensures timely intervention and appropriate next steps.
Summary:
A: Notifying the operating room is premature and unnecessary at this point.
B: Pulsation may not always be normal and warrants immediate action.
C: Removing the tube without professional guidance can be harmful to the client.