A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?
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Solution
Option C: Accompanying him will offer moral support, enabling him to face the rest of the world.
Option A: A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone.
Option B: Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence.
Option D: Waiting to consult a physical therapist is unnecessary.
Certain substances increase the amount of urine produced. These include:
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Solution
Option A: Fluids containing caffeine have a diuretic effect.
Options B and C: Beets and urinary analgesics, such as Pyridium (Phenazopyridine), can color urine red.
Option D: Kaopectate is an antidiarrheal medication.
To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. She should notify the physician if the urine output is:
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Solution
Option A: A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake.
Which of the following statement is incorrect about a patient with dysphagia?
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Solution
Option C: A patient with dysphagia (difficulty swallowing) requires assistance with feeding. Feeding himself is a long-range expected outcome.
Options A, B, and D: Soft foods, Fowler’s or semi-Fowler’s position, and oral hygiene before eating should be part of the feeding regimen.
The most common deficiency seen in alcoholics is:
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Solution
Option A: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition.
The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
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Solution
Option A: Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration, and dyspnea.
Options B, C, and D: High-humidity air and chest physiotherapy help liquefy and mobilize secretions.
Which of the following patients is at greatest risk for developing pressure ulcers?
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Solution
Option B: Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. Age is also a factor. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk.
The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
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Solution
Option C: Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay.
Options A, B, and D: Absence of the apical, radial, or femoral pulse is abnormal and should be investigated.
Palpating the midclavicular line is the correct technique for assessing
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Solution
Option D: The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth, fifth, or sixth intercostal space. Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration.
All of the following can cause tachycardia except:
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Solution
Option D: Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of contraction, rate of impulse conduction and blood flow through the coronary vessels. Fever, exercise, and sympathetic stimulation all increase the heart rate.