Nokea
A 54-year-old client has cholelithiasis and is admitted for an elective cholecystectomy. The client is 5 feet 3 inches tall, weighs 205 pounds, and has smoked one pack of cigarettes per day for 35 years. The client will be NPO at midnight. When the client's spouse asks why the client cannot have breakfast the morning before surgery, the nurse should explain:
- A. Your spouse is a good-sized person and it won't hurt to miss breakfast.
- B. Eating breakfast and having food in the stomach could cause vomiting and aspiration during surgery.
- C. Your spouse will be too busy in the morning preparing for surgery to have time to eat breakfast.
- D. Not eating breakfast will prevent fecal contamination of the abdominal operative site.
Correct Answer: B
Rationale: The client's size has nothing to do with an NPO status. Clients are at greatest risk for aspiration and vomiting during surgery when food and/or liquids are in the stomach. Preparation on the morning of surgery is time consuming, but it does not affect a client's NPO status. The gallbladder lies under the surface of the liver and is a part of the biliary tract, not the intestinal tract. Cholecystectomy does not involve the intestinal tract or its contents.
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Grace was diagnosed with hyperparathyroidism after a workup to determine the cause of her elevated calcium levels. The greatest concern in a patient with hypercalcemia would be:
- A. Cardiac arrhythmia and sinus arrest.
- B. Nausea and vomiting.
- C. Constipation and dehydration.
- D. Kidney stones and muscle weakness.
Correct Answer: D
Rationale: The correct answer is Kidney stones and muscle weakness (D). Hypercalcemia is commonly associated with kidney stones due to increased calcium excretion in urine. Muscle weakness is also a common symptom due to the effect of high calcium levels on neuromuscular function.
Which of the following is a sign of presbyopia?
- A. Difficulty seeing distant objects
- B. Difficulty seeing close objects
- C. Double vision
- D. Color blindness
Correct Answer: B
Rationale: Presbyopia is the gradual loss of near focusing ability, making it difficult to see close objects.
When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct Answer: A
Rationale: Step 1: Encouraging the client and family to be active partners promotes safety by involving them in care decisions.
Step 2: This empowers the client to voice concerns and preferences, enhancing their safety.
Step 3: Monitoring hand hygiene (B) is important but doesn't directly involve the client's active participation.
Step 4: Offering family to stay (C) is supportive but doesn't directly engage the client in promoting their own safety.
Step 5: Advising to wear armband (D) is a procedural measure, not a collaborative safety-promoting action.
A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?
- A. I will reduce my sodium intake to help control my blood pressure.
- B. I need to start walking at least 30 minutes most days of the week.
- C. I can continue drinking alcohol as long as it is not in excess.
- D. I will check my blood pressure regularly at home.
Correct Answer: C
Rationale: The correct answer is C because excessive alcohol consumption can raise blood pressure. Step 1: Alcohol can lead to hypertension. Step 2: Limiting alcohol intake is crucial in managing hypertension. Step 3: Choices A, B, and D promote healthy behaviors that help control blood pressure. Summary: Choice C is incorrect as it goes against hypertension management, while choices A, B, and D align with lifestyle modifications for hypertension.
A 72-year-old male client had the Foley catheter removed today, which was inserted during the transurethral resection of the prostate (TURP). The client is concerned about the urinary incontinence he has experienced since removal of the Foley catheter. The nurse should explain to the client that:
- A. he should not be concerned, because it will be quickly resolved.
- B. urinary incontinence is usually temporary.
- C. he should notify the nurse when this happens.
- D. this is related to the bladder spasms and will soon stop.
Correct Answer: B
Rationale: Urinary incontinence is usually temporary, but the problem may take some time to resolve, especially in an older male. Bladder spasms are not the cause of the client's incontinence.