Nokea
A client develops lymphedema after a left mastectomy with lymph node dissection. Which of the following should be included in the discharge teaching plan? Select all that apply.
- A. Do not allow blood pressures or blood draws in the affected arm.
- B. Avoid application of sunscreen on the left arm.
- C. Use an electric razor for shaving.
- D. Immobilize the left arm.
- E. Elevate the left arm.
- F. Perform hand pump exercises.
Correct Answer: A,C,E,F
Rationale: Preventing trauma (A, C), elevating the arm (E), and performing exercises (F) reduce lymphedema risk and promote lymphatic drainage. Sunscreen (B) is safe, and immobilization (D) is not recommended.
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The nurse is taking care of a client with Clostridium difficile (C. difficile). The nurse should do which of the following to prevent the spread of infection? Select all that apply.
- A. Wear a particulate respirator.
- B. Wear sterile gloves when providing care.
- C. Cleanse hands with alcohol-based hand sanitizer.
- D. Wash hands with soap and water.
- E. Wear a protective gown when in the client's room.
Correct Answer: D,E
Rationale: To prevent the spread of C. difficile, washing hands with soap and water (D) is essential as alcohol-based sanitizers are ineffective against its spores, and wearing a protective gown (E) prevents contamination. A respirator (A) is unnecessary, sterile gloves (B) are not required (clean gloves suffice), and alcohol sanitizer (C) is ineffective. CN: Safety and infection control; CL: Create
A client is admitted to the surgical floor after having bowel surgery. The nurse observes that the client's urine output has decreased from 50 to 20 mL/hour. Which of the following is the most likely cause?
- A. Bowel obstruction.
- B. Adverse effect of opioid analgesics.
- C. Hemorrhage.
- D. Hypertension.
Correct Answer: B
Rationale: Opioid analgesics, commonly used post-surgery, can cause urinary retention by relaxing the bladder, reducing urine output. This is the most likely cause in this scenario.
A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to:
- A. Call for the physician.
- B. Start an I.V. line.
- C. Obtain a portable chest radiograph.
- D. Draw blood for laboratory studies.
Correct Answer: A
Rationale: Indigestion in a client with cardiac risk factors may indicate an MI. Calling the physician promptly ensures rapid evaluation and intervention, such as ECG or medications.
The primary healthcare provider (PHCP) prescribes medication via the buccal route. To correctly administer this medication, the nurse plans to place the medication
- A. in the client's ear while holding the pinna down and back.
- B. under the client's tongue.
- C. in the client's mouth toward the cheek.
- D. into the client's nasal passage.
Correct Answer: C
Rationale: Buccal administration involves placing the medication in the cheek pouch for absorption through the oral mucosa.
A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client:
- A. Adds dried fruit to cereal and baked goods.
- B. Cooks tomato-based foods in iron pots.
- C. Drinks coffee or tea with meals.
- D. Adds vitamin C to all meals.
Correct Answer: C
Rationale: Drinking coffee or tea with meals inhibits iron absorption due to tannins, which bind to iron and reduce its bioavailability. This indicates a lack of understanding of nutritional counseling for anemia, as the client should avoid these beverages during meals. Adding dried fruit (iron source), cooking in iron pots (increases iron content), and consuming vitamin C (enhances iron absorption) are appropriate strategies.