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A client diagnosed with acquired immunodeficiency syndrome (AIDS) is reporting fatigue. The nurse educates the client on ways to conserve energy. Which statement indicates that the teaching was effective?
- A. Bathe before eating breakfast.
- B. Sit for as many activities as possible.
- C. Stand in the shower instead of taking a bath.
- D. Group all tasks to be performed early in the morning.
Correct Answer: B
Rationale: The client is taught to conserve energy by sitting for as many activities as possible, including dressing, shaving, preparing food, and ironing. The client should also sit in a shower chair instead of standing while showering. The client needs to prioritize activities such as eating breakfast before bathing, and the client should intersperse each major activity with a period of rest.
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The nurse has provided home care instructions to a client with prostate cancer who has been hospitalized for a transurethral resection of the prostate (TURP). Which statement by the client indicates the need for further teaching?
- A. Prune juice needs to be included in my diet.
- B. I need to avoid strenuous activity for 4 to 6 weeks.
- C. My intake of water needs to be at least 6 to 8 glasses daily.
- D. I can't lift or push objects that weigh more than 30 pounds.
Correct Answer: D
Rationale: The client needs to be advised to avoid strenuous activity for 4 to 6 weeks and avoid lifting items that weigh more than 20 pounds. Straining during defecation is avoided to prevent bleeding. Prune juice is a satisfactory bowel stimulant. The client needs to consume a daily intake of at least 6 to 8 glasses of nonalcoholic fluids to minimize clot formation.
A client is receiving intravenous (IV) antibiotic therapy at home via an intermittent IV catheter. In order to facilitate the early detection of IV therapy complications, which intervention should be included in the client's education?
- A. Protect the IV site continually.
- B. Keep the IV site clean and dry.
- C. Report local pain, drainage, or edema.
- D. Apply pressure to the IV site if it dislodges.
Correct Answer: C
Rationale: The nurse instructs the client to report clinical indicators of an IV site infection, including pain, drainage, and edema because the early detection of infection decreases the risk of septicemia, tissue loss, and devastating complications. The remaining options are reasonable aspects of client teaching for IV therapy at home, but they are not surveillance methods.
A home care nurse is instructing a mother of a child diagnosed with cystic fibrosis (CF) about the appropriate dietary measures. Which diet should the nurse tell the mother that the child needs to consume?
- A. Low-calorie, low-fat diet
- B. High-calorie, restricted fat
- C. Low-calorie, low-protein diet
- D. High-calorie, high-protein diet
Correct Answer: D
Rationale: Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy and fat-soluble vitamin supplements are administered. Fat restriction is not necessary.
The nurse has provided instructions to a client who is receiving external radiation therapy. Which statement by the client indicates a need for further teaching regarding self-care related to the radiation therapy?
- A. I need to eat a high-protein diet.
- B. I need to avoid exposure to sunlight.
- C. I need to wash my skin with a mild soap and pat it dry.
- D. I need to apply pressure on the irritated area to prevent bleeding.
Correct Answer: D
Rationale: The client receiving external radiation therapy should avoid pressure on the irritated area and wear loose-fitting clothing. Specific health care provider instructions would be necessary to obtain if an alteration in skin integrity occurred as a result of the radiation therapy. The remaining options are accurate measures regarding radiation therapy.
A client is being treated for an atrial dysrhythmia with quinidine gluconate. Which statement by the client indicates to the nurse that the medication instructions about what to do if a dose is missed have been understood?
- A. I should call my primary health care provider.
- B. I should take the next prescribed dose as usual.
- C. I should take the dose as soon as I realize I've missed it.
- D. I take two doses of the medication at the next scheduled time.
Correct Answer: B
Rationale: Quinidine gluconate needs to be taken exactly as prescribed. Because of the action and effects of this medication, the client should be instructed to take the medication if remembered within 2 hours of the missed dose, or omit the dose and then resume the normal schedule. There is no need to call the doctor. It is not safe to take the dose whenever it is remembered or to take an extra dose.