Nokea
A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been effective if the client makes which of the following statements?
- A. I will have my parents put bed-boards on my bed.
- B. I should decrease my caloric intake.
- C. I should only take tub baths.
- D. I can remove the brace for one hour a day.
Correct Answer: D
Rationale: should be worn at all times, except when bathing
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The nurse is caring for a client with a history of congestive heart failure.
- A. Which instruction is most important for a client with congestive heart failure?
- B. Weigh yourself daily at the same time.
- C. Take extra diuretics if you feel short of breath.
- D. Eat a high-sodium diet to maintain electrolytes.
- E. Avoid exercise to prevent cardiac strain.
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early, a key indicator of worsening heart failure. Extra diuretics require medical orders, high-sodium diets worsen fluid retention, and exercise is encouraged within limits.
The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure (CHF). Which of the following in the client's history would have a direct correlation with her current problem?
- A. History of rheumatic fever four years ago.
- B. Presence of ventricular septal defect as an infant.
- C. Heart disease in both the maternal and the paternal families.
- D. Persistent ear infections and mastoiditis as a child.
Correct Answer: A
Rationale: most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve
A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to
- A. avoid intercourse for 48 hours before the examination.
- B. avoid douching for 24 hours prior to her appointment.
- C. withhold all foods and fluids 12 hours before the appointment.
- D. save her first voided urine specimen the morning of her appointment.
Correct Answer: B
Rationale: douching would affect appearance of cells in vaginal smear, would make test inaccurate
A patient is admitted with abdominal pain and nausea. The physician orders stool for guaiac times three days.
The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?
- A. I'll remind the patient to use the bedpan instead of the bathroom toilet.
- B. I'll use a tongue blade to collect a small amount of stool in a clean container.
- C. I'll get a couple of specimens this afternoon because the patient is having loose stools.
- D. I'll ask the patient if he has ingested any red meat recently.
Correct Answer: C
Rationale: Strategy: Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) easier to get specimen (2) doesn't need to be sterile container (3) correct-ordered to be collected over 3-day period (4) may cause false-positive reading
The neonatal nurse is instructing the family of a newborn about an apnea monitor.
The nurse should be MOST concerned if a family member makes which of the following statements?
- A. We will be able to leave our baby for brief periods of time.'
- B. We plan to sleep by our baby's crib.'
- C. We can remove the monitor during our baby's bath.'
- D. A family member will closely watch the monitor all the time.'
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates that you are looking for an incorrect statement. (1) appropriate behavior (2) appropriate behavior (3) appropriate behavior (4) correct-indicates a feeling that monitor may not let them know if their infant stops breathing