Nokea
A client presents to the clinic with a large abscess on the right thigh. The healthcare provider incises and drains the abscess. Which instruction should the nurse provide to the client upon discharge?
- A. Avoid showering until the wound is completely closed
- B. Perform daily wound care and dressing changes
- C. Apply heat to the wound for 15 minutes twice a day
- D. Take the prescribed antibiotic until the wound is fully healed
Correct Answer: B
Rationale: After incision and drainage of an abscess, it is crucial to perform daily wound care and dressing changes to prevent infection and promote healing. Avoiding showering until the wound is completely closed (choice A) may not be practical or necessary. Applying heat to the wound (choice C) can increase the risk of infection and delay healing. While taking the prescribed antibiotic (choice D) is important, wound care and dressing changes are more directly related to promoting healing and preventing complications.
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What might be suggested to a client with fibrocystic breasts in an attempt to help relieve symptoms?
- A. Increase intake of high-calcium foods in your diet
- B. Wear a supportive bra during the day and at night
- C. Take over-the-counter pain relievers
- D. Perform regular breast massage
Correct Answer: B
Rationale: The correct answer is B: 'Wear a supportive bra during the day and at night.' Wearing a supportive bra is essential for individuals with fibrocystic breasts as it helps relieve discomfort by providing necessary support to reduce strain on breast tissue. Option A is incorrect as high-calcium foods are not directly related to symptom relief in fibrocystic breasts. Option C is not the first-line recommendation and may not address the underlying issue. Option D, performing regular breast massage, is not typically recommended and may not provide significant relief for fibrocystic breast symptoms.
After completing her first chemotherapy treatment, what behavior indicates that a female client with breast cancer understands her discharge care needs?
- A. She refuses to take anti-nausea medication.
- B. She rents movies and borrows books to pass time at home.
- C. She plans to resume strenuous physical activity immediately.
- D. She reports severe fatigue and inability to perform daily activities.
Correct Answer: B
Rationale: Renting movies and borrowing books for use during recovery indicates the client is planning restful activities at home, which aligns with appropriate post-chemotherapy care. Choices A, C, and D are incorrect because refusing anti-nausea medication can lead to complications, resuming strenuous physical activity immediately can be harmful, and reporting severe fatigue and inability to perform daily activities may indicate a need for medical attention rather than understanding discharge care needs.
A client is receiving treatment for glaucoma. Which class of medications is commonly used to decrease intraocular pressure?
- A. Anticholinergics
- B. Beta blockers
- C. Alpha blockers
- D. Diuretics
Correct Answer: D
Rationale: Diuretics are commonly used to decrease intraocular pressure in clients with glaucoma. They work by reducing the production of aqueous humor in the eye or by increasing its outflow. Anticholinergics (Choice A) are not typically used in the treatment of glaucoma and can even increase intraocular pressure. Beta blockers (Choice B) are also commonly used in glaucoma treatment as they reduce aqueous humor production. Alpha blockers (Choice C) are not the first-line treatment for glaucoma and are not as commonly used as diuretics or beta blockers.
A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to melt ice chips in the mouth
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this scenario. This helps maintain comfort and prevent dryness in clients with nasogastric tubes. Allowing the client to melt ice chips in the mouth may not address oral care needs effectively. Providing mints to freshen the breath is not the priority when the client needs oral care. Swabbing the mouth with glycerin swabs may not be as effective as performing thorough oral care with a tooth sponge.
A client receiving IV antibiotics for sepsis reports itching and has a rash on the chest. What is the nurse's first action?
- A. Administer an antihistamine as prescribed.
- B. Stop the infusion and notify the healthcare provider.
- C. Slow the infusion rate and monitor the client.
- D. Administer epinephrine subcutaneously.
Correct Answer: B
Rationale: The correct action for the nurse to take first when a client receiving IV antibiotics for sepsis reports itching and a rash on the chest is to stop the infusion and notify the healthcare provider. This is crucial in preventing the allergic reaction from worsening. Administering an antihistamine (choice A) may address the symptoms but does not address the primary concern of stopping the infusion. Slowing the infusion rate and monitoring the client (choice C) may not be sufficient if the reaction is severe. Administering epinephrine subcutaneously (choice D) is not the first-line intervention for this situation.