Question 5121)
A client who had a laryngectomy is nearly ready for discharge. Which instruction is most appropriate for the nurse to give?
A. “Always be sure you have a buddy with you when you go swimming or boating.”
B. “You may take a tub bath, but you should not take a shower.”
C. “Be sure to have only liquids for another three weeks.”
D. “Never cover your stoma with anything.”
Answer: B
Explanation: Showering is not usually allowed because water will go into the stoma. The client will never be able to swim. The client does not need a liquid diet for three weeks. The stoma should be covered with a special absorbent scarf to filter and warm the air.
Question 5122)
A client asks the nurse why inspiration through the nose is preferable to inspiring through the mouth. What is the best response?
A. It produces greater blood oxygen levels
B. It is easier to breathe through the nose.
C. The nares humidify, warm, and filter the air.
D. Mouth breathing dilutes the air and reduces the amount of air entering the lungs.
Answer: C
Explanation: The purpose of the nares is to humidify, warm, and filter the air before it enters the lungs. Breathing through the nose does not produce greater blood oxygen levels. It is not easier to breathe through the nose. Mouth breathing does not dilute the air
Question 5123)
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
A. Suction deeper to pick up secretions
B. Gently withdraw suction tubing to allow suction or coughing out of mucus
C. Remove the suction as quickly as possible
D. Put the suction tube in and out several times to pick up secretions
Answer: B
Explanation: Allow the client to cough. The client will frequently cough out the mucus. If he does not, then the nurse can suction to pick up secretions. The client’s cough is more powerful than the suction catheter.
Question 5124)
An adult man fell off a ladder and hit his head and lost consciousness. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. The nursing care plan will most likely include which of the following?
A. Elevate head of bed 15 to 30 degrees
B. Encourage fluids to 1000 mL every eight hours
C. Assist the client to cough and deep breathe every two hours
D. Perform chest physical therapy every four hours while awake
Answer: A
Explanation: The head of the bed should be slightly elevated to allow gravity drainage of fluid and reduce cerebral edema. Coughing and forcing fluids are contraindicated because they may raise intracranial pressure. Chest physical therapy would be apt to raise intracranial pressure.
Question 5125)
A teenager is admitted following a seizure. The next day, the nurse goes into his room and finds him lying on the floor starting to have a seizure. What action should the nurse take at this time?
A. Carefully observe the seizure and gently restrain him
B. Attempt to put an airway in his mouth so he does not swallow his tongue, and observe the type and duration of the seizure
C. Place something soft under his head, carefully observe the seizure, and protect him from injury
D. Shout for help so that someone can help you move him away from the furniture
Answer: C
Explanation: Protect his head from injury, and observe the seizure. Never try to restrain a seizing person. Current thinking indicates to not put an airway in the mouth. Placing something soft under his head will help to protect his head from injury. The question does not indicate that the client is in danger from the furniture.
Question 5126) An adult is being treated with phenytoin (Dilantin) for a seizure disorder. Five days after starting the medication, he tells the nurse that his urine is reddish-brown in color. What action should the nurse take?
A. Inform him that this is a common side effect of phenytoin (Dilantin) therapy
B. Test the urine for occult blood
C. Report it to the physician because it could indicate a clotting deficiency
D. Send a urine specimen to the lab
Answer: A
Explanation: He is receiving phenytoin (Dilantin), which frequently causes the urine to turn reddish-brown in color. There is no indication for testing the urine or notifying the physician. The finding should be recorded on the client’s chart.
Question 5127)
The nurse is caring for a client who has recently had a cerebrovascular accident (CVA). When positioning the client and supporting her extremities, the nurse must remember that when voluntary control of muscles is lost:
A. the feet will maintain a position of eversion.
B. the upper extremities will rotate externally
C. the hip joint will rotate internally
D. flexor muscles will become stronger than extensors.
Answer: D
Explanation: Flexor muscles are stronger than extensors, causing flexion contractures. The hip joint tends to rotate externally.
Question 5128)
A stroke victim regains consciousness three days after admission. She has rightsided hemiparesis and hemiplegia and also has expressive aphasia. She becomes upset when she is unable to say simple words. The best approach for the nurse is to do which of the following?
A. Stay with her and give her time and encouragement in attempting to speak.
B. Say, “I’m sure you want a glass of water. I’ll get it for you.”
C. Say, “Don’t get upset. You rest now and I’ll come back later and try to talk to you then.”
D. Encourage her attempts and say, “Don’t worry, it will get easier every day.”
Answer: A
Explanation: Offering help is always therapeutic. This approach will help her to express herself. The nurse should not routinely anticipate her needs because this does not encourage attempts at speech. Telling her not to get upset is not therapeutic. Encouraging her attempts to speak is therapeutic, but telling her not to worry is not therapeutic
Question 5129)
A young man was swimming at the beach when an exceptionally large wave caused him to be drawn under the water. His family members found him in the water and pulled him ashore. He states that he heard something snap in his neck. When a nurse arrives, he is conscious and lying on his back. He states that he has no pain. He is unable to move his legs. How should he be transported?
A. Position him in a prone position and place on a backboard.
B. Apply a neck collar and position supine on a backboard.
C. Log roll him to a rigid backboard
D. Position in an upright position with a firm neck collar.
Answer: B
Explanation: He may have a neck or spinal cord injury. The neck and back should be supported and maintained in a rigid position. He should be transported in the position in which he was found. He should not be turned.
Question 5130)
A client who is recovering from a spinal cord injury complains of blurred vision and a severe headache. His blood pressure is 210/140. The most appropriate initial action for the nurse to take is to:
A. check for bladder distention
B. place him in the Trendelenburg position
C. administer PRN pain medication
D. position him on his left side.
Answer: A
Explanation: The symptoms suggest autonomic hyperreflexia, which is usually caused by bladder distention. The patient will need to be catheterized and the physician notified. Autonomic hyperreflexia is a medical emergency. The head is usually elevated to reduce blood pressure.
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