Nokea
A client and his family facing the end stage of a terminal illness might be best served by:
- A. a rehabilitation center.
- B. an extended care facility.
- C. Hospice.
- D. a crisis intervention center.
Correct Answer: C
Rationale: Hospice has the belief that more humanized alternative care for dying clients is needed than is being provided in hospitals, which focus mostly on medical cures. No matter where the care is delivered, Hospice provides a specialized interdisciplinary team of health care professionals who work together to manage client care.
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The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?
- A. It is normal for your breasts to be tender. You should call the physician if you also have redness and fatigue.
- B. Because your baby was delivered vaginally, you might have to urinate more frequently.
- C. It is normal to run a low-grade temperature for a few days. If it is higher than 100°F, call your physician.
- D. Be sure to call your physician if your vaginal discharge becomes bright red.
Correct Answer: D
Rationale: The vaginal discharge after birth is called lochia, and it changes from red (rubra) to serosa (clear) on the third postpartum day. If it returns to red or contains clots, it could signal impending hemorrhage or infection and the physician should be notified.
A patient has recently been prescribed (Norvasc). Which of the following side effect/s should the patient specifically watch out for?
- A. Hypotension and Angina
- B. Hypertension
- C. Lower extremity edema
- D. Peripheral sensory loss and SOB
Correct Answer: A
Rationale: Both angina and hypotension are associated with Norvasc's side effects.
When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:
- A. Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes.'
- B. If you haven't been sexually active throughout your life, you will not be able to participate in sexual activity in old age.'
- C. When intercourse isn't possible, many of your sexual needs can be met through intimacy and touch.'
- D. You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time.'
Correct Answer: A
Rationale: To provide the best response, the nurse must identify what the elder is asking. Concern is being expressed about whether elders can engage in sexual activity. The most therapeutic response by the nurse is Choice 1. In this choice, the nurse acknowledges that elders can physically engage in sexual activity and have no psychological barriers to the same. All of the other choices contain facts but are not the best initial response. Choice 1 opens the conversation for the expression of further concerns about sexual issues.
Who should receive the hepatitis A vaccine?
- A. children who are 18 months of age
- B. infants, who should receive the vaccination at birth
- C. people who travel to other countries
- D. individuals who might come into contact with blood
Correct Answer: C
Rationale: Hepatitis A is for individuals who travel or persons with chronic liver disease. Infants receive the hepatitis B vaccine at birth. DTaP is administered at 18 months of age. Individuals who come into contact with blood should be immunized against hepatitis B.
Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. sterile water
- D. Heparin sodium
Correct Answer: A
Rationale: Normal saline (0.9% sodium chloride) is isotonic and safe for flushing IV lines before and after blood administration, preventing cell lysis or clotting.