Mr. Jones is undergoing an open lung biopsy in the morning, and the nurse is educating the patient regarding the postoperative period. Which of the following statements should be included in the education?

"You will be discharged home immediately following the procedure."

"You will not need any supplemental oxygen."

"You most likely will have a chest tube inserted to allow your lung to re-expand."

"You will need to collect a sputum specimen."

Answer and Explanation

The Correct Answer is C

A. Discharge immediately following an open lung biopsy is unlikely. The patient will need observation post-procedure for complications such as bleeding, infection, or pneumothorax, and it usually requires a stay in the hospital for monitoring.
B. It is unlikely that supplemental oxygen will not be needed following an open lung biopsy. The patient may require oxygen post-procedure due to potential respiratory compromise, such as atelectasis or pneumothorax.
C. A chest tube is commonly inserted after an open lung biopsy to allow the lung to re-expand and to drain air or fluid that may accumulate in the pleural space. This is a standard part of the postoperative care for this procedure.
D. Collecting a sputum specimen is not typically necessary immediately after an open lung biopsy. The focus will be on monitoring the patient’s respiratory status, ensuring proper lung expansion, and preventing complications like pneumothorax or bleeding.

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Correct Answer is A

Explanation

A. Cerebral edema is the most dangerous complication associated with the administration of hypotonic fluids in patients with diabetic ketoacidosis (DKA). This occurs because hypotonic fluids cause rapid shifts in fluid and electrolytes, which can lead to swelling of the brain, especially in children. The risk is heightened if fluids are replaced too quickly.
B. Polyuria is a common symptom of diabetic ketoacidosis due to high blood glucose levels and osmotic diuresis, but it is not caused by hypotonic fluid administration.
C. Hypokalemia is a potential risk in DKA but typically arises from the shift of potassium from the extracellular to intracellular space during treatment, especially with insulin administration, not from the use of hypotonic fluids.
D. Metabolic acidosis is a hallmark of diabetic ketoacidosis itself and is caused by the accumulation of ketones. It is not caused by hypotonic fluid replacement.

A. Place the patient in a lateral recovery position for better drainage of the secretions. B. Activate the rapid-response team. C. Keep monitoring the oxygen saturation and respiratory rate. D. Increase the humidification of the patient's oxygen.

Correct Answer is A

Explanation

A. Placing the patient in a lateral recovery position is the best immediate action. This position helps facilitate drainage of secretions, especially after a laryngectomy, which can reduce the risk of aspiration and airway obstruction. The blood-tinged mucus may be due to recent surgery and should be monitored for changes.
B. The activation of the rapid-response team may be necessary if the patient’s condition worsens or becomes critical, but there is no indication of an acute life-threatening event based on the blood-tinged mucus alone.
C. Monitoring the oxygen saturation and respiratory rate is important, but it is a secondary concern compared to providing a position that promotes drainage and prevents aspiration.
D. Increasing humidification of the oxygen may help keep the airway moist, but the immediate priority should be ensuring proper positioning to allow secretion drainage and prevent aspiration.

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Mr. Jones is undergoing an open lung biopsy in the morning, and the nurse is educating the patient regarding the postoperative period. Which of the following statements should be included in the education?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which condition may be observed due to incorrect fluid replacement with hypotonic fluids in patients with diabetic ketoacidosis?

Correct Answer is A

Explanation

After observing blood-tinged mucous when suctioning a patient who has just arrived on the medical-surgical unit after a laryngectomy, which action by the nurse is best?

Correct Answer is A

Explanation

A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse expect?

A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?

A nurse is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should the nurse include in the teaching?

Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.)

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.)