Nokea
A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?
- A. A heart rate of 72 beats per minute
- B. A blood pressure of 110/70 mm Hg
- C. Pupils equal and reactive to light
- D. Client reports headache
Correct Answer: C
Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.
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A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?
- A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
- B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate.
- C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
- D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.
Correct Answer: A
Rationale: The most crucial point to reinforce to the patient after a vasectomy is the need for continued contraception until it is confirmed that the ejaculate is sperm-free. Choice A emphasizes this by highlighting the importance of using another form of contraception until the healthcare provider confirms the absence of sperm. This is essential to prevent unintended pregnancies. Choices B, C, and D do not address the key point of ensuring contraception until sperm absence is confirmed and are therefore not as important to reinforce in this scenario.
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
- A. The tube will drain fluid from your chest.
- B. The tube will remove excess air from your chest.
- C. The tube controls the amount of air that enters your chest.
- D. The tube will seal the hole in your lung.
Correct Answer: B
Rationale: The correct answer is B: 'The tube will remove excess air from your chest.' In a spontaneous pneumothorax, air accumulates in the pleural space, causing lung collapse. The chest tube is inserted to remove this excess air, allowing the lung to re-expand. Choices A, C, and D are incorrect because the primary purpose of a chest tube in pneumothorax is to evacuate air, not fluid, control air entry, or seal a lung hole.
The client is being taught to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?
- A. Three apricots
- B. Medium banana
- C. Naval orange
- D. Baked potato
Correct Answer: D
Rationale: The correct answer is D. A baked potato is high in potassium and helps prevent digitalis toxicity by maintaining adequate potassium levels. While choices A, B, and C all contain some potassium, a baked potato is a more concentrated source of potassium compared to three apricots, a medium banana, or a naval orange. Therefore, the client should choose a baked potato to better meet the dietary needs for preventing digitalis toxicity.
During the care of a client with a salmonella infection, what is the primary nursing intervention to limit transmission?
- A. Wash hands thoroughly before and after client contact
- B. Wear gloves when in contact with body secretions
- C. Double glove when in contact with feces or vomitus
- D. Wear gloves when disposing of contaminated linens
Correct Answer: A
Rationale: The correct answer is to wash hands thoroughly before and after client contact when caring for a client with a salmonella infection. This approach is crucial in preventing the transmission of the infection. While wearing gloves when in contact with body secretions (Choice B), double gloving when in contact with feces or vomitus (Choice C), and wearing gloves when disposing of contaminated linens (Choice D) are important infection control measures, the primary intervention to limit the spread of salmonella is proper hand hygiene.
A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?
- A. You should increase the fiber in your diet.
- B. You should increase the calories in your diet.
- C. You should decrease the dairy products in your diet.
- D. You should decrease the amount of vitamin D in your diet.
Correct Answer: C
Rationale: The correct statement for a client who is lactose intolerant is to decrease dairy products since lactose intolerant individuals should avoid dairy to prevent symptoms like bloating, diarrhea, and gas. Increasing fiber (Choice A) or calories (Choice B) is not directly related to lactose intolerance. Decreasing vitamin D (Choice D) is not necessary as lactose intolerance is about the sugar in dairy, not vitamin D.