Nokea
A 65-year-old client who recently retired from many years of working full-time for a company has become increasingly unmotivated and states he feels as though he has no purpose. Which of the following recommendations are most appropriate? Select all that apply.
- A. Volunteer or get a part-time job.
- B. Participate in community activities.
- C. Join a senior citizen's group.
- D. Be thankful he can afford to retire.
- E. Ask to have retirement reversed.
Correct Answer: A,B,C
Rationale: Volunteering/part-time work (A), community activities (B), and senior groups (C) provide purpose. Gratitude (D) is dismissive, and reversing retirement (E) is impractical.
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An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse's discharge teaching?
- A. The child should not play on his rocking horse.
- B. Applying warm compresses will decrease pain.
- C. Diapering should be avoided for 1-2 weeks.
- D. The child will need a special diet to promote healing.
Correct Answer: A
Rationale: Avoiding straddling activities like rocking horses prevents strain on the surgical site post-hypospadias repair.
A client with cancer is to undergo a bone scan. The nurse should:
- A. Force fluids 24 hours before the procedure
- B. Ask the client to void immediately before the study
- C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
- D. Cover the client's reproductive organs with an x-ray shield
Correct Answer: B
Rationale: Voiding immediately before a bone scan ensures the bladder is empty, reducing interference with pelvic imaging and improving the accuracy of the scan.
The ED nurse is caring for a client whose native tongue is not English. The client speaks Korean and only understands a few words of English. The nurse understands that which response is best regarding how to communicate with this client?
- A. ask a bilingual family member to tell the client to point to where the pain is
- B. call the oncology unit and ask for the nurse who is a native Korean to come and translate
- C. show the client the equipment before using it, such as indicating that an IV line will be placed in the arm
- D. call for an official Korean interpreter on the facility's translator hotline to communicate with the client, family, and health care provider
Correct Answer: D
Rationale: Using an official interpreter ensures accurate, unbiased communication, adhering to ethical and legal standards for patient care.
The nurse enters a client's room and finds him lying on the floor. The client says to the nurse, 'I fell because I was trying to go to the bathroom and no one answered my call light.' Which of the following actions by the nurse are correct? Select all that apply.
- A. assist the client back to bed
- B. complete an incident report
- C. notify the health care provider
- D. assess the client for any injuries
- E. document in the medical record that the client fell
Correct Answer: A,B,C,D,E
Rationale: All actions are appropriate: assist the client safely, assess for injuries, notify the provider, complete an incident report, and document the fall to ensure proper care and follow-up.
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
- A. A family vacation in the Rocky Mountains
- B. Chaperoning the local boys club on a snow-skiing trip
- C. Traveling by airplane for business trips
- D. A bus trip to the Museum of Natural History
Correct Answer: D
Rationale: A bus trip to a museum is a low-exertion activity at sea level, minimizing the risk of hypoxia compared to high-altitude or strenuous activities.