Nokea
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
- A. Altered nutrition: less than body requirements
- B. Potential complication hemorrhage
- C. Ineffective individual coping
- D. Fluid volume excess
Correct Answer: B
Rationale: Potential complication hemorrhage. Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
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A 67-year-old man for an intravenous pyelogram (IVP).
The nurse prepares a 67-year-old man for an intravenous pyelogram (IVP). Which of the following information is MOST important for the nurse to obtain before the procedure?
- A. The date of the client's last EKG.
- B. The time of the client's last meal.
- C. A list of the client's allergies.
- D. A list of the medications the client takes at home.
Correct Answer: C
Rationale: Strategy: All answers are assessments. Determine why you would make the assessment and how it relates to the situation. (1) electrical activity of heart, not most important (2) should be NPO for 6-8 h, not most important (3) correct-involves injection of radiopaque dye, used to identify lesions and assess function, allergy to iodine is life-threatening (4) not most important
The nurse is supervising care given to clients on a medical/surgical unit.
The nurse should intervene if which of the following is observed?
- A. A nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition.
- B. A nurse injects insulin through a single-lumen percutaneous central catheter for client receiving total parenteral nutrition.
- C. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen.
- D. A nurse wears a disposable particulate respirator when administering rifampin to a client with tuberculosis.
Correct Answer: C
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) appropriate procedure, prevents airborne contamination (2) insulin is the only medication that can be given, compatible with TPN (3) correct-applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur (4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hour
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to
- A. Avoid smoking near the client
- B. Turn off oxygen during meals
- C. Adjust the liter flow to 10 as needed
- D. Remind the client to keep mouth closed
Correct Answer: A
Rationale: Avoid smoking near the client. Oxygen supports combustion, posing a fire risk if smoking occurs nearby.
The nurse is teaching testicular self-exam to a group of young men. Which information should be included in the instructions? Select all that apply.
- A. Perform the exam once a week.
- B. Palpate each testicle between the thumb and forefinger.
- C. Palpate the spermatic cord.
- D. Look in the mirror for dimpling.
- E. Testicles should be the same size.
- F. Both testicles should be at the same level.
Correct Answer: B,C
Rationale: Palpating the testicle and spermatic cord detects lumps or abnormalities during testicular self-exam. Monthly (not weekly) exams are recommended, dimpling is for breast exams, and testicles may differ slightly in size and level.
The nurse is the leader of a group of mentally retarded adults. The nurse instructs the group members to ignore another client whenever he interrupts others who are speaking. To evaluate the progress of this intervention, the nurse should
- A. measure improvement by counting the number of times the client succeeds.
- B. measure improvement by counting the number of interruptions.
- C. assess the ability of the group to control the client’s interruptions.
- D. count the number of tokens and earned privileges given for interruptions.
Correct Answer: A
Rationale: Counting successful non-interruptions measures the client’s behavioral improvement, the goal of the intervention. Options B, C, and D are less effective: counting interruptions tracks failures, group control is secondary, and tokens are not given for interruptions.