Nokea
You are working in a community health clinic and a client needs instructions for care of a hordeolum (sty) to the right upper eyelid. What is the first treatment that the client should try?
- A. Apply warm compresses 4 times/day.
- B. Gently perform hygienic eyelid scrubs.
- C. Obtain prescription for antibiotic drops.
- D. Contact the ophthalmologist.
Correct Answer: A
Rationale: Warm compresses are the first-line treatment for a hordeolum, as they promote drainage and reduce inflammation.
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What information in Mr. Singer’s history is most likely associated with his diagnosis of cancer of the larynx?
- A. Shortness of breath on exertion
- B. Abdominal distention
- C. Alteration in voice
- D. Loss of appetite
Correct Answer: C
Rationale: Hoarseness or voice changes are early signs of laryngeal cancer.
The client with a chest tube after a coronary artery bypass graft has significantly slowed drainage. What action is most important for the nurse to take?
- A. Increase the setting on the suction.
- B. Notify the provider immediately.
- C. Re-position the chest tube.
- D. Take the tubing apart to assess for clots.
Correct Answer: B
Rationale: The correct answer is B: Notify the provider immediately. This is the most important action because significantly slowed drainage in a client with a chest tube after surgery can indicate a potential complication like a blocked tube or bleeding. Notifying the provider allows for prompt assessment and intervention to prevent further complications.
Increasing the suction setting (choice A) without knowing the reason for slowed drainage can potentially worsen the situation. Re-positioning the chest tube (choice C) may not address the underlying issue causing the slowed drainage. Taking the tubing apart to assess for clots (choice D) should not be done by the nurse as it can introduce the risk of infection and requires sterile technique.
A student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select one that does not apply)
- A. Age
- B. Hypertension
- C. Obesity
- D. Smoking
Correct Answer: A
Rationale: The correct answer is A: Age. Age is a non-modifiable risk factor for coronary artery disease, meaning it cannot be changed or controlled. Hypertension, obesity, and smoking are modifiable risk factors as they can be managed through lifestyle changes or medical interventions. By controlling blood pressure, maintaining a healthy weight, and quitting smoking, individuals can reduce their risk of developing coronary artery disease. Age, however, is a natural process that cannot be altered. Therefore, focusing on managing modifiable risk factors is crucial in preventing coronary artery disease.
Which member of the surgical team does not scrub into the operating room?
- A. The surgeon.
- B. The circulating nurse.
- C. The scrub nurse or surgical tech.
- D. The holding area nurse.
Correct Answer: B
Rationale: The circulating nurse does not scrub into the operating room. Their role is to manage activities outside the sterile field and assist with tasks such as retrieving supplies and documenting care.
Following a gastric resection, a 70-year-old male client is admitted to the Post-Anesthesia Care Unit (PACU). The client was extubated prior to leaving the OR suite. Upon arrival at the PACU, the nurse should first:
- A. check the client's airway to feel for the amount of air exchange, noting the rate, depth, and quality of respirations.
- B. obtain pulse and blood pressure readings, noting the rate and quality of the client's pulse.
- C. reassure the client that his surgery is over and that he is in the recovery room.
- D. review the doctor's orders to administer any medications ordered.
Correct Answer: A
Rationale: Adequate air exchange and tissue oxygenation depends upon competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but is secondary to airway management. Re-orienting a client to time, place, and person and knowing that their surgery is over is important, but is secondary to airway management and taking vital signs. Airway management takes precedence over the physician's orders, unless the orders specifically relate to airway management.