Nokea
A client being discharged to home after angioplasty via the right femoral groin has received the catheter insertion site discharge instructions from the nurse. Which client statement indicates that the client understands the instructions?
- A. Coolness or discoloration of the right foot is expected.
- B. I should expect a large area of bruising at the right groin.
- C. Temperature as high as 101°F (38.3°C) is not unusual a few days after the procedure.
- D. Mild discomfort in the right groin may occur, and Tylenol should relieve the pain.
Correct Answer: D
Rationale: The client may feel some mild discomfort at the catheter insertion site after angioplasty. This is usually relieved by analgesics such as acetaminophen (Tylenol). The client is taught to report to the primary health care provider any neurovascular changes to the affected leg; bleeding or bruising at the insertion site; and signs/symptoms of local infection, such as drainage at the site or increased temperature.
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A client is diagnosed with hyperphosphatemia caused by hypoparathyroidism. To prevent worsening of the condition, the nurse should instruct the client to avoid which food selections? Select all that apply.
- A. Fish
- B. Eggs
- C. Coffee
- D. Grapes
- E. Bananas
- F. Whole-grain breads
Correct Answer: A,B,F
Rationale: Food items and liquids that are naturally high in phosphates include fish, eggs, milk products, whole grains, vegetables, and carbonated beverages, and they should be avoided by the client with hyperphosphatemia. Coffee, grapes, and bananas are acceptable for this client to consume because their phosphate levels are not significant.
A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the reddened area. After counseling the client to relieve pressure on the area by adhering to a turning schedule, which action by the nurse is most appropriate?
- A. Teaching the client to feel for reddened areas
- B. Asking a family member to assess the skin daily
- C. Teaching the client to use a mirror for skin assessment
- D. Scheduling the client to return to the clinic daily for a skin check
Correct Answer: C
Rationale: The client should be encouraged to be as independent as possible. The most effective means of skin self-assessment for this client is with the use of a mirror. The redness cannot be felt. Asking a family member to assess the skin daily does not promote independence. It is unnecessary and unrealistic for the client to return to the clinic daily for a skin check.
A client is receiving lipids (fat emulsion) intravenously at home, and the client's spouse manages the infusion. The home care nurse makes a visit and discusses potential side and adverse effects of the therapy with the client and the spouse. After the discussion, the nurse expects the spouse to verbalize that, in case of a suspected adverse effect, which action is the priority?
- A. Stop the infusion.
- B. Contact the nurse.
- C. Take the client's blood pressure.
- D. Contact the local area emergency response team.
Correct Answer: A
Rationale: Signs/symptoms of an adverse effect to lipids (fat emulsion) include chest and back pain, chills, vertigo, cyanosis, diaphoresis, dyspnea, fever, flushing, headache, nausea and vomiting, and thrombophlebitis of the vein. The priority action is to stop the infusion to limit the adverse response. Although contacting the nurse, taking the client's blood pressure, and contacting the local emergency response team are correct interventions, the priority is to stop the infusion.
Using Naegele's Rule, calculate the estimated date of birth for a client who reports the first day of the last menstrual period was August 7.
- A. 7-May
- B. 14-May
- C. 31-Oct
- D. 14-Nov
Correct Answer: B
Rationale: Naegele's Rule: Add 1 year, subtract 3 months, add 7 days. August 7 + 1 year = August 7 next year; minus 3 months = May 7; plus 7 days = May 14.
The mother of a teenage client diagnosed with an anxiety disorder is concerned about her daughter's progress after discharge. She states that her daughter 'stashes food, eats all the wrong things that make her hyperactive,' and 'hangs out with the wrong crowd.' To assist the mother with preparing for her daughter's discharge, the nurse advises the mother to implement which action in order to promote optimal health?
- A. Restrict the daughter's socializing time with her school friends.
- B. Consider taking time off to help her daughter readjust to the home environment.
- C. Limit the amount of chocolate and caffeine products that are available in the home.
- D. Keep her daughter out of school until she proves that she can adjust to the school environment.
Correct Answer: C
Rationale: Limiting chocolate and caffeine reduces anxiety triggers in clients with anxiety disorders. Restricting socializing, taking time off work, or keeping her out of school are impractical or unhealthy, hindering social and emotional adjustment.