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A client is undergoing a bone marrow aspiration and biopsy. What is the best way for the nurse to help the client handle her stress?
- A. Allow the client's family to stay with her as long as possible.
- B. Stay with the client and hold her hand without speaking.
- C. Encourage the client to take slow, deep breaths.
- D. Allow the client time to express her feelings.
Correct Answer: C
Rationale: Encouraging slow, deep breaths helps reduce anxiety and promotes relaxation during the stressful bone marrow aspiration procedure. Family presence, hand-holding, and expressing feelings are supportive but less effective for immediate stress management.
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A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?
- A. Every 5 minutes.
- B. Every 10 minutes.
- C. Every 15 minutes.
- D. Every 20 minutes.
Correct Answer: C
Rationale: Monitoring temperature every 15 minutes during active rewarming ensures timely detection of hypothermia resolution or hyperthermia, balancing safety and practicality.
Which of the following health promotion activities would be appropriate for the nurse to suggest that the client with cirrhosis add to the daily routine at home?
- A. Supplement the diet with daily multivitamins.
- B. Limit daily alcohol intake.
- C. Take a sleeping pill at bedtime.
- D. Limit contact with other people whenever possible.
Correct Answer: A
Rationale: Multivitamins (A) address nutritional deficiencies common in cirrhosis. Alcohol (B) must be completely avoided, sleeping pills (C) risk encephalopathy, and social isolation (D) is unnecessary.
The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching?
- A. I should eat a high-protein, high-carbohydrate diet to provide energy.'
- B. It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin.'
- C. I should avoid constipation to decrease chances of bleeding.'
- D. If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured.'
Correct Answer: C
Rationale: Avoiding constipation (C) prevents ammonia buildup and bleeding risks. High-protein diets (A) may worsen encephalopathy, acetaminophen (B) is hepatotoxic, and cirrhosis is irreversible (D).
A client has recently been diagnosed with type 2 diabetes mellitus and is to take tolbutamide (Orinase). When teaching the client about the drug, the nurse explains that tolbutamide is believed to lower the blood glucose level by which of the following actions?
- A. Potentiating the action of insulin.
- B. Lowering the renal threshold of glucose.
- C. Stimulating insulin release from functioning beta cells in the pancreas.
- D. Combining with glucose to render it inert.
Correct Answer: C
Rationale: Tolbutamide, a sulfonylurea, stimulates insulin release from pancreatic beta cells, helping to lower blood glucose levels in type 2 diabetes.
Which dietary restriction is critical in acute renal failure?
- A. Low sodium.
- B. High protein.
- C. Low carbohydrate.
- D. High potassium.
Correct Answer: A
Rationale: Low sodium prevents fluid retention and hypertension in acute renal failure.