Nokea
Nurse providing pre-op teaching for client scheduled for mastectomy next day. Which client statement indicates client is ready to learn?
- A. I don't want my spouse to see my incision
- B. Will you be able to give me pain meds after surgery?
- C. Can you tell me about how long the surgery will take?
- D. My roommate listens to everything I say
Correct Answer: C
Rationale: The correct answer is C because the client's question shows readiness to learn about the procedure, indicating an active interest in understanding the surgery process. This demonstrates the client's engagement and willingness to absorb information, which is crucial for pre-op teaching. Choices A, B, and D do not directly relate to seeking information about the surgery itself and do not demonstrate readiness for learning. Therefore, they are incorrect.
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Nurse admitting a client with acute cholecystitis to the med-surg unit. Which of the following actions are essential to the admission procedure? (Select all that apply.)
- A. Explain roles of other care delivery staff
- B. Begin discharge planning
- C. Provide info about advance directives
- D. Document the client's wishes about organ donation
- E. Introduce client to his roommate
Correct Answer: A,B,C,E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: Explaining roles of other care delivery staff helps manage client expectations and ensures effective communication among healthcare team members.
B: Beginning discharge planning early improves continuity of care and helps prevent delays in the discharge process.
C: Providing information about advance directives ensures the client's wishes are documented and respected in case of incapacitation.
E: Introducing the client to his roommate promotes social interaction and helps create a comfortable environment for the client.
Summary:
Choice D is incorrect as documenting organ donation wishes is not directly related to the admission process for acute cholecystitis.
Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. "I have my own apt now
- B. but it's not easy living away from my parents."
- C. It's been so stressful for me to even think about having my own family.
- D. I don't even know who I am yet, & now I'm supposed to know what to do.
- E. My girlfriend is pregnant, & I don't think I have what it takes to be a good father.
Correct Answer: C
Rationale: The correct answer is C: "It's been so stressful for me to even think about having my own family." This is the priority issue as it indicates the young adult is struggling with the idea of starting a family, which can have long-term implications. This concern may affect their mental health, relationships, and decision-making. Option A is about independence, B about transitioning from parents, D about self-identity, and E about impending fatherhood. While important, these issues are not as urgent as the stress related to starting a family.
Nursing instructor is reviewing steps of nursing process with group of students. Students should identify which of following data as objective? (Select all that apply.)
- A. Respiratory rate of 22/min with even, unlabored respirations
- B. I can only walk 3 blocks before my legs start to hurt'
- C. Pain level 3/10
- D. Skin pink, warm, dry
- E. Urine output 300 mL/8 hr
- F. Dressing clean, dry, intact
Correct Answer: A, D, E, F
Rationale: Objective data refers to measurable and observable information.
A: Respiratory rate and breathing pattern can be directly observed and counted, making it objective data.
D: Skin color, temperature, and moisture can be seen and felt, making it objective data.
E: Urine output is quantifiable and measurable, making it objective data.
F: The cleanliness, dryness, and integrity of a dressing can be visually assessed, making it objective data.
The other choices involve subjective experiences or interpretations (B), self-reported pain level (C), or may require additional assessments beyond direct observation (G).
Nurse is reviewing nutrition guidelines with parents of 2 yo. Which parent statement should indicate to nurse that they understand feeding guidelines for this age group?
- A. I should keep feeding my son whole milk until he's 3 yo
- B. It's okay for me to give him a cup of apple juice with each meal
- C. I'll give my son about 2 tablespoons of each food at mealtimes
- D. My son loves popcorn, & I know it's better for him than sweets
Correct Answer: C
Rationale: The correct answer is C: "I'll give my son about 2 tablespoons of each food at mealtimes." This statement indicates an understanding of appropriate portion sizes for a 2-year-old, as small portions are recommended to avoid overfeeding. It shows awareness of the child's dietary needs and helps prevent picky eating.
Choice A is incorrect as the recommendation is to switch to reduced-fat milk after the age of 2. Choice B is incorrect because excessive juice consumption can lead to poor nutrition and dental issues. Choice D is incorrect as popcorn may pose a choking hazard for young children and should be given cautiously.
Nurse has removed a sterile pack from its outside cover & placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?
- A. Flap closest to body
- B. Right side flap
- C. Left side flap
- D. Flap farthest from the body
Correct Answer: D
Rationale: The correct answer is D: Flap farthest from the body. Unfolding this flap first ensures that the sterile contents inside the pack remain protected from contamination by the nurse's body and hands. Starting with the farthest flap minimizes the risk of accidental touching or contamination of the sterile instruments or supplies. Unfolding the closest flap (choice A) or the side flaps (choices B and C) first could potentially expose the sterile contents to contamination. Therefore, unfolding the flap farthest from the body is the most appropriate and logical step to maintain sterility and ensure safe patient care during the procedure.