Nokea
A client is being discharged after having a coronary artery bypass grafting x5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.
- A. Report any itching, tingling, or numbness around your incisions
- B. Report any redness, swelling, warmth, or drainage from your incisions
- C. Soak incisions in the tub once a week, then clean with hydrogen peroxide and apply lotion
- D. Wash incisions daily with soap and water in the shower and gently pat them dry
- E. Wear an elastic compression hose on your legs and elevate them while sitting
Correct Answer: A, B, D
Rationale: Reporting sensory changes (A), signs of infection (B), and washing gently (D) promote healing. Soaking and peroxide (C) can disrupt healing, and compression hose (E) are not routinely needed.
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The nurse is making assignments for the day's care. Which assignment should not be given to the nursing assistant?
- A. Emptying the Foley catheter bag
- B. Administering a Fleet's enema
- C. Measuring the oral intake
- D. Feeding a client with depression
Correct Answer: B
Rationale: Administering an enema requires nursing judgment and is outside a nursing assistant's scope. Other tasks are appropriate for a nursing assistant.
A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, 'I'm so worried that my future spouse is going to call off our engagement.' What is the best response by the nurse?
- A. Are you concerned about how the surgery will affect your sexuality?'
- B. If you are concerned about infertility, you could always bank your sperm.'
- C. The cancer is at an early stage. You are going to be fine.'
- D. What have you and your future spouse discussed about your condition?'
Correct Answer: D
Rationale: Asking about discussions with the spouse (D) encourages the client to share concerns and clarifies the situation. Options A, B, and C assume specific fears or provide reassurance without exploration.
A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which of the following additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.
- A. Blood pressure 82/64 mm Hg
- B. Crackles on auscultation
- C. Distended jugular veins
- D. Pulse 120/min
- E. Shoulder pain
Correct Answer: A, D, E
Rationale: Low blood pressure (A), tachycardia (D), and shoulder pain (E) indicate hemorrhage from a ruptured ectopic pregnancy. Crackles (B) and jugular vein distension (C) are unrelated.
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
- A. Place pillows under the knees
- B. Use elastic stockings continuously
- C. Encourage range of motion and ambulation
- D. Massage the legs twice daily
Correct Answer: C
Rationale: Encourage range of motion and ambulation. Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk due to other factors.
The nurse in a long-term care facility is caring for a client with major depressive disorder who is reporting difficulty sleeping. The client gets up during the night, paces the hallway, wrings the hands, and appears teary. Which of the following actions should the nurse take? Select all that apply.
- A. Arrange for the client to receive at least 20 minutes of natural sunlight each day
- B. Encourage the client to take naps during the day
- C. Instruct the client to engage in physical exercise just before bedtime
- D. Provide the client with a cup of warm milk in the evening
- E. Spend time with the client in a quiet environment just before bedtime
- F. Suggest that the client listen to soft music before going to bed
Correct Answer: A, D, E, F
Rationale: Natural sunlight exposure (A) helps regulate circadian rhythms and improve mood. Warm milk (D) contains tryptophan, which promotes sleep. A quiet environment (E) and soft music (F) reduce stimulation and promote relaxation. Naps (B) may disrupt nighttime sleep, and exercise before bedtime (C) can be stimulating.