- (Topic 7)
Which of the following physician??s orders would the nurse question on a client with chronic arterial insufficiency?
Correct Answer:B
(A) Neurovascular checks are a routine part of assessment with clients having this diagnosis. (B) Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. (C) Arteriogram is a routine diagnostic order. (D) Smoking is highly correlated with this disorder.
- (Topic 4)
A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, ??The doctor said I have stones that need to be removed; where are they??? The nurse knows that the best explanation for this is to tell her that:
Correct Answer:C
(A)Cholelithiasisis the correct term used to describe the presence of stones in the gallbladder. (B)Nephrolithiasis,orrenal calculi,is the correct term used to describe the presence of stones in the kidney. (C)Choledocholithiasisis the correct term used to describe the presence of stones in the common bile duct. (D)Cholecystitisis the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.
- (Topic 2)
A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:
Correct Answer:D
(A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B) In pulling the breast away from the infant without breaking suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple trauma. (D) By inserting a finger into the infant??s mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma.
- (Topic 4)
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours?? postburn?
Correct Answer:D
(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client??s hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48–72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client??s airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
- (Topic 6)
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
Correct Answer:D
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1–2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.