Question

The client has just returned from the post anesthesia care unit after undergoing a laryngectomy. Which intervention should initially be included in the plan of care?

Answer 1

Correct Answers:

Maintain the head of the bed at 30 to 40 degrees

Rationale :

🔷 Elevating the head of the bed supports airway patency and promotes pulmonary drainage after a laryngectomy.

🔷 This position reduces the risk of aspiration and edema, which are common concerns post-surgery.

🔷 It enhances lung expansion and aids in the prevention of respiratory complications.

🔷 Interventions like feeding or speech therapy are premature immediately post-op.

🔷 Early airway positioning is critical for post-anesthesia care and recovery.

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Answer 2

Correct Answers:

Administer 100% oxygen before suctioning

Rationale :

🟢 Pre-oxygenation helps prevent hypoxemia during suctioning, which removes air along with secretions.

🟢 This is especially important in clients with excessive secretions, as suctioning can cause transient hypoxia.

🟢 Administering 100% oxygen increases the oxygen reserve during the brief suctioning period. 🟢 Suctioning should be limited to 10–15 seconds to minimize risk.

🟢 Other actions, like cuff deflation or removing cannulas, are not appropriate during suctioning.

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Answer 3

Correct Answers:

Unstageable pressure injury

Rationale :

🟣 Necrotic eschar covering the wound bed prevents visibility of making staging impossible.

🟣 This condition is classified as unstageable until debridement allows evaluation of depth and tissue involvement.

🟣 Pressure injuries are staged based on depth, tissue type, and visibility.

🟣 Eschar may conceal deeper damage such as exposed bone or tendon.

🟣 Prompt wound care consultation is typically warranted for accurate reassessment.

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Answer 4

Correct Answers:

One week after menses

Rationale :

🔶 Performing a breast self-exam one week after menses ensures the breasts are least tender and swollen.

🔶 Hormonal changes during and before menstruation can cause breast engorgement, making palpation harder.

🔶 This timing improves accuracy in detecting abnormal lumps or changes.

🔶 Teaching clients to perform monthly exams at this consistent time enhances compliance and early detection.

🔶 Consistency is key in tracking long-term breast health.

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Answer 5

Correct Answers:

Encourage the client to ambulate.

Rationale :

🟡 After abdominal surgery, gas pains are common due to intestinal inactivity and air.

🟡 Ambulation stimulates peristalsis, promoting the passage of gas and reducing discomfort.

🟡 Opioids may worsen gas retention and slow motility.

🟡 Iced liquids can cause intestinal cramping, not relief.

🟡 Early mobilization also helps prevent postoperative complications like DVT.

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Answer 6

Correct Answers:

Beneficence

Rationale :

💗 Beneficence refers to actions that promote well-being and comfort for the client.

💗 The nurse staying overtime and ensuring pain control exemplifies kindness, compassion, and advocacy.

💗 Administering prescribed pain relief honors the client’s dignity and alleviates suffering.

💗 It aligns with the nurse’s ethical duty to act in the client’s best interest.

💗 This principle is fundamental in end-of-life care.

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Answer 7

Correct Answers:

Communicating orally and in writing

Rationale :

🔴 Expressive aphasia, often due to Broca’s area damage, impairs the ability to verbalize or write thoughts.

🔴 Clients can often understand language, but speech output is limited or incoherent.

🔴 Non-verbal methods such as gestures or boards may be helpful for communication.

🔴 It’s important to be patient and allow extra time for responses.

🔴 This differs from receptive aphasia, which affects comprehension.

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Answer 8

Correct Answers:

"Syphilis is only a concern if I have pain or discharge."

Rationale :

⚠️Syphilis can be asymptomatic in early stages or present as painless ulcers.

⚠️Believing it’s only a concern with pain is a misconception, risking ongoing transmission.

⚠️The bacterium remains contagious, especially during the primary and secondary stages.

⚠️Teaching should emphasize the importance of screening, treatment, and sexual safety.

⚠️ Education corrects myths and reduces public health risks.

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Answer 9

Correct Answers:

Cool, pale extremities with weak pulses

Rationale :

🩻 Arterial insufficiency reduces blood flow to the lower extremities, causing coolness, pallor, and diminished pulses.

🩻 Clients may also report claudication or numbness.

🩻 This is different from venous insufficiency, which involves warm, swollen limbs.

🩻 The skin may appear shiny, hairless, or dry with arterial disease.

🩻 Proper assessment ensures accurate vascular classification and management.

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Answer 10

Correct Answers:

Ask the client to rate their pain on a scale of 0 to 10

Rationale :

🔷 Using a numeric rating scale provides a subjective and quantifiable measure of pain.

🔷 It's the most reliable indicator because pain is individual and self-reported.

🔷 Vital signs can be altered by other factors and aren't definitive for pain.

🔷 Facial expressions may mislead; some clients mask discomfort.

🔷 Asking “if” they're in pain may elicit a yes/no without indicating severity.

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RN Medical-Surgical Exam III~2025

No.

1 :
The client has just returned from the post anesthesia care unit after undergoing a laryngectomy. Which intervention should initially be included in the plan of care?

2 :
The nurse is performing tracheostomy care on a client with excessive secretions. Which action will prevent hypoxemia during suctioning?

3 :
The client is admitted with an open pressure injury with necrotic eschar tissue covering the base. How should the nurse stage this client's pressure injury?

4 :
The nurse is educating a client about performing a breast self-examination. The client correctly identifies which of the following as the best time to perform this exam?

5 :
The nurse is caring for a client who is postoperative after abdominal surgery and reporting "gas pains." What action by the nurse can assist the client with alleviating the discomfort associated with gas?

7 :
A client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with which action?

8 :
The nurse is caring for a client with a painless ulcer on their penis who has tested positive for syphilis. Which comment from the client requires additional education?

9 :
The client presents with a diagnosis of arterial insufficiency. When examining the lower extremities, the nurse expects to observe which clinical manifestation?

10 :
The nurse is assessing a client recently returned from surgery. Which is the most appropriate action for the nurse to assess the client's pain?

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RN Medical-Surgical Exam III~2025

No.

1 : The client has just returned from the post anesthesia care unit after undergoing a laryngectomy. Which intervention should initially be included in the plan of care?

2 : The nurse is performing tracheostomy care on a client with excessive secretions. Which action will prevent hypoxemia during suctioning?

3 : The client is admitted with an open pressure injury with necrotic eschar tissue covering the base. How should the nurse stage this client's pressure injury?

4 : The nurse is educating a client about performing a breast self-examination. The client correctly identifies which of the following as the best time to perform this exam?

5 : The nurse is caring for a client who is postoperative after abdominal surgery and reporting "gas pains." What action by the nurse can assist the client with alleviating the discomfort associated with gas?

7 : A client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with which action?

8 : The nurse is caring for a client with a painless ulcer on their penis who has tested positive for syphilis. Which comment from the client requires additional education?

9 : The client presents with a diagnosis of arterial insufficiency. When examining the lower extremities, the nurse expects to observe which clinical manifestation?

10 : The nurse is assessing a client recently returned from surgery. Which is the most appropriate action for the nurse to assess the client's pain?

1 :
The client has just returned from the post anesthesia care unit after undergoing a laryngectomy. Which intervention should initially be included in the plan of care?

2 :
The nurse is performing tracheostomy care on a client with excessive secretions. Which action will prevent hypoxemia during suctioning?

3 :
The client is admitted with an open pressure injury with necrotic eschar tissue covering the base. How should the nurse stage this client's pressure injury?

4 :
The nurse is educating a client about performing a breast self-examination. The client correctly identifies which of the following as the best time to perform this exam?

5 :
The nurse is caring for a client who is postoperative after abdominal surgery and reporting "gas pains." What action by the nurse can assist the client with alleviating the discomfort associated with gas?

7 :
A client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with which action?

8 :
The nurse is caring for a client with a painless ulcer on their penis who has tested positive for syphilis. Which comment from the client requires additional education?

9 :
The client presents with a diagnosis of arterial insufficiency. When examining the lower extremities, the nurse expects to observe which clinical manifestation?

10 :
The nurse is assessing a client recently returned from surgery. Which is the most appropriate action for the nurse to assess the client's pain?