The nurse is teaching a client and her family about home care following a laryngectomy. Which statement by the client indicates a need for further teaching from the nurse?
- A. I will purchase a Medic-Alert bracelet.
- B. I can wear loose-fitting turtlenecks to cover the stoma.
- C. I can resume water aerobics once my doctor says it is okay.
- D. I have a lot of green houseplants year-round throughout my home.
Correct Answer: C
Rationale: Water aerobics pose a drowning risk due to water entering the stoma, requiring further teaching. Other statements are appropriate for laryngectomy care.
You may also like to solve these questions
The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis?
- A. air embolism
- B. clotting of the graft site
- C. dialysis encephalopathy
- D. disequilibrium syndrome
Correct Answer: D
Rationale: Disequilibrium syndrome causes tachypnea, hypotension, and anxiety due to rapid shifts in fluid and electrolytes during dialysis.
While preparing a client for a colonoscopy, the nurse would be correct to implement which interventions? Select all that apply.
- A. instruction on high fiber diet the day before the procedure
- B. instruction that a sedative will be administered before the procedure
- C. instruction not to eat or drink 6-12 hours before the procedure
- D. instruction not to eat or drink 18 hours before the procedure
Correct Answer: B,C
Rationale: A sedative (B) is used for comfort, and fasting 6-12 hours (C) ensures a clear colon for colonoscopy. High fiber (A) is contraindicated, and 18 hours (D) is excessive.
The nurse is caring for a client who just returned from a total hip arthroplasty. A student nurse is helping provide care for this client. Which action by the student nurse requires intervention by the nurse?
- A. The student nurse floats the client's heels with a pillow.
- B. The student nurse positions the client with the legs adducted.
- C. The student nurse applies the sequential compression device (SCD) per orders.
- D. The student nurse encourages deep breathing and incentive spirometer use every 2 hours.
Correct Answer: B
Rationale: Adducting the legs post-hip arthroplasty risks dislocation; legs should be kept abducted. Other actions (A, C, D) are appropriate for preventing complications.
The nurse is reviewing arterial blood gases (ABGs) on a client. Which finding would prompt the nurse to notify the health care provider?
- A. pH 7.42
- B. pH 7.67
- C. HCO3 24 mEq/L
- D. paCO2 41 mmHg
- E. paCO2 44 mmHg
Correct Answer: B
Rationale: pH 7.67 indicates alkalosis (normal 7.35-7.45), requiring provider notification. Other values are within normal ranges (HCO3 22-26, paCO2 35-45).
A young child with a rash that's raised and has circumscribed areas filled with fluid comes to the school nurse. What type of rash should the nurse document?
- A. maculopapular rash
- B. heat rash
- C. vesicular rash
- D. pustular rash
Correct Answer: C
Rationale: A rash with raised, fluid-filled, circumscribed areas is a vesicular rash (C), as seen in conditions like chickenpox. Maculopapular (A) is flat/spotted, heat rash (B) is prickly, and pustular (D) contains pus.