A client undergoes a total laryngectomy and tracheostomy formation. On discharge, which instruction should the nurse give to the client and family
A. "Clean the tracheostomy tube with alcohol and water. "
B. "Family members should continue to talk to the client. "
C. "Oral intake of fluids should be limited for 1 week only. "
D. "Limit the amount of protein in the diet. "
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For a client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to
A. prevent respiratory alkalosis.
B. lower arterial pH.
C. promote carbon dioxide elimination.
D. maintain partial pressure of arterial oxygen (PaO2) above 80 mmH
Signs and symptoms of retinal detachment include which of the following
A. Painless decrease in vision, a veil over the visual field, and flashing lights.
B. A veil over the visual field, increased intraocular pressure, and yellow-green halos around visual images.
C. Photophobia, yellow-green halos around visual images, and blurred vision.
D. Unilateral eye inflammation, a cloudy cornea, and a moderately dilated pupil.
The nurse is caring for a client during the fourth stage of labor. Which of the following nursing interventions would be LEAST appropriate
A. Catheterization to protect the bladder from trauma.
B. Perineal assessments for swelling and bleeding.
C. Vital signs and fundal checks every 15 minutes.
D. Time with the neonate to initiate breast-feedin
A client who suffered blunt chest trauma in a car accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub--a classic sign of acute pericarditis. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position
A. Semi-Fowler’s.
B. Leaning forward while sitting.
C. Supine.
D. Pron
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