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A client has been prescribed a clonidine patch, and the nurse has instructed the client regarding the use of the patch. Which client statement indicates a need for further teaching?
- A. I intend to change the patch every 7 days.
- B. I need to trim the patch if an edge becomes loose.
- C. It's important to put the patch on a hairless site on my torso.
- D. It's alright to leave the patch in place during bathing or showering.
Correct Answer: B
Rationale: The clonidine patch should not be trimmed because it will alter the medication dose. If it becomes slightly loose, it should be covered with an adhesive overlay from the medication package. If it becomes very loose or falls off, it should be replaced. It is changed every 7 days, and is left in place when bathing or showering. The clonidine patch should be applied to a hairless site on the torso or the upper arm. The patch is discarded by folding it in half with the adhesive sides together.
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A client has had same-day surgery to insert a ventilating tube into the tympanic membrane. Which statement assures the nurse that the client understands the discharge instructions?
- A. I will use a shower cap when taking a shower.
- B. I was told to try and avoid taking medications for pain.
- C. I need to wash my hair quickly; taking 2 minutes or less.
- D. Swimming is allowed only if I keep my head above water.
Correct Answer: A
Rationale: After the insertion of tubes into the tympanic membrane, it is important to avoid getting water in the ears. A shower cap or earplug may be used when showering if allowed by the primary health care provider. Swimming, showering without a shower cap or ear plugs, and washing the hair are avoided after surgery until the time frame designated for each is identified by the surgeon. The client should take medication as advised for postoperative discomfort.
The nurse has completed diet teaching for a client on a low-sodium diet for the treatment of hypertension. Which statement by the client should indicate to the nurse that there is a need for further teaching?
- A. Frozen foods are usually lowest in sodium.
- B. This diet will help lower my blood pressure.
- C. This diet is not a replacement for my antihypertensive medications.
- D. The reason I need to lower my salt intake is to reduce fluid retention.
Correct Answer: A
Rationale: A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension as a result of increased fluid volume. Frozen foods use salt as a preservative, which increases their sodium content. Canned foods are extremely high in sodium. Fresh foods are best.
During a health assessment the nurse provides instructions to a client regarding the testicular self-examination (TSE). Which statement by the client indicates that the client needs further teaching regarding TSE?
- A. I know to report any small lumps.
- B. I should examine myself every 2 months.
- C. I should examine myself after I take a warm shower.
- D. I know it's normal to feel something that is cord-like in the back.
Correct Answer: B
Rationale: TSE should be performed every month. Small lumps or abnormalities should be reported. The spermatic cord finding is normal. After a warm bath or shower, the scrotum is relaxed, which makes it easier to perform TSE.
The student nurse is listening to an orthopedic lecture on preoperative education and knee surgeries. Which statement by the student nurse indicates that the teaching has been effective?
- A. Crutch walking instructions should be scheduled before surgery.
- B. Crutch walking instructions should be given on the first postoperative day.
- C. Crutch walking instructions should be scheduled on the second postoperative day.
- D. Crutch walking instructions should be scheduled at the time of discharge after surgery.
Correct Answer: A
Rationale: It is best to assess crutch-walking ability and instruct the client with regard to the use of the crutches before surgery because this task can be difficult to learn when the client is in pain and not used to the imbalance that may occur after surgery. None of the remaining options are appropriate times to teach a client about crutch walking.
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.