Nokea
The nurse anticipates the client will likely require-------as evidenced by the client’s---------
- A. temperature
- B. stool test results
- C. respiratory rate
- D. an endoscopy
- E. an antifungal prescription
- F. oxygen via nonrebreather mask
Correct Answer: B,D
Rationale: The correct answers are B (stool test results) and D (an endoscopy). The nurse anticipates the client will likely require a stool test based on gastrointestinal symptoms, such as abdominal pain or blood in stool. Stool test results can help diagnose gastrointestinal issues. Additionally, the nurse may anticipate the need for an endoscopy to further investigate gastrointestinal symptoms, like persistent reflux or difficulty swallowing. Choices A, C, E, and F are less likely as they are not directly related to gastrointestinal issues. Choice E (antifungal prescription) may be relevant in case of fungal infection, but gastrointestinal symptoms would not typically prompt this. Choice F (oxygen via nonrebreather mask) is more related to respiratory issues.
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Which of the following positions should the nurse take to place the client at ease?
- A. Sit in a chair next to the bed
- B. Stand at the side of the bed.
- C. Sit on the bed next to the client.
- D. Stand at the foot of the bed
Correct Answer: A
Rationale: The correct answer is A: Sit in a chair next to the bed. This position allows the nurse to be at eye level with the client, promoting a sense of equality and rapport. Sitting also conveys a sense of attentiveness and availability for conversation. Standing at the side of the bed (B) may create a sense of distance. Sitting on the bed next to the client (C) may invade personal space. Standing at the foot of the bed (D) can be perceived as intimidating.
A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can go jogging after 2 weeks.â€
- B. I should bend at the waist when putting on my shoes.â€
- C. I can lift objects that are less than 10 pounds.
- D. I can resume activities: such sewing.â€
Correct Answer: D
Rationale: The correct answer is D: "I can resume activities such as sewing." This indicates an understanding of the teaching because it shows the client recognizes the need to avoid strenuous activities that may increase intraocular pressure, thus risking damage to the repaired retina. Sewing is a low-impact activity that does not involve heavy lifting or sudden movements, making it safe for the client postoperatively.
Choice A is incorrect because jogging is a high-impact activity that should be avoided for several weeks post-surgery. Choice B is incorrect because bending at the waist can increase intraocular pressure, which is not recommended post-detached retina repair. Choice C is incorrect as lifting objects, even if less than 10 pounds, can also increase intraocular pressure.
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs
- D. Apply, an orthotic to the client's foot
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. This intervention helps to maintain proper alignment of the foot, preventing contractures that can occur due to prolonged immobility. Placing a pillow under the client's knees (choice A) is beneficial for reducing pressure on the lower back but does not specifically address foot contractures. Similarly, placing a towel roll under the client's neck (choice B) is helpful for neck support but does not prevent foot contractures. Aligning a trochanter wedge between the client's legs (choice C) is aimed at hip alignment and not foot contractures. Therefore, the most appropriate intervention to prevent foot contractures in an immobile client is applying an orthotic to the client's foot.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys leading to blood in the urine. This is known as hematuria. Polyuria (choice A) is not typically seen in this condition as the kidneys are not able to effectively filter urine. Hypotension (choice B) is unlikely as fluid retention and hypertension are more common due to decreased kidney function. Weight loss (choice C) is not a common finding as the condition often leads to fluid retention. Therefore, hematuria is the most expected finding in acute glomerulonephritis.
Which of the following questions is the priority for the nurse to ask the client?
- A. How do you manage your behavior?
- B. Do you have a criminal record?
- C. How do you get along with your peers at school?
- D. Do you have thoughts of harming yourself?
Correct Answer: D
Rationale: The correct answer is D. The nurse's priority is to assess for any immediate danger or harm to the client. Asking about thoughts of harming oneself is crucial in determining the client's safety. This question helps identify the client's risk of suicide and allows for timely intervention if needed. Choices A, B, and C focus on different aspects of the client's behavior and relationships, which are important but not as urgent as assessing for suicidal ideation. It is essential to address safety concerns first before exploring other areas.