A client who has had a laparoscopic cholecystectomy receives discharge instructions from the nurse. Which statement indicates that the client has understood the instructions?
- A. I need to maintain a low-fat diet for the next 6 months
- B. I can remove the dressing from my incision tomorrow and take a shower
- C. I can anticipate some nausea for several days after surgery
- D. I can return to work in 4 to 6 weeks
Correct Answer: B
Rationale: Removing the dressing and showering the day after a laparoscopic cholecystectomy is standard, as incisions are small. A low-fat diet may be advised but not for a fixed 6 months, nausea is not expected, and return to work is typically sooner.
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The mother of a 3-year-old child tells the nurse her child is 'fussy' and not as 'easy going' as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. The nurse should instruct the mother to:
- A. Allow the child to determine when feeding should occur.
- B. Not to feed the child if he cries.
- C. Provide structured feeding times and routines.
- D. Give the child finger foods and let him eat when he wants.
Correct Answer: C
Rationale: Structured feeding times and routines help establish consistent eating habits, reducing fussiness by providing predictability for the child.
A new breast-feeding mother experiencing breast engorgement is provided with instructions regarding care for the condition. Which statement by the mother indicates to the nurse that she possesses an understanding of the measures that will provide comfort for the engorgement?
- A. I will breast-feed using only one breast.
- B. I will apply cold compresses to my breasts.
- C. I will avoid the use of a bra while my breasts are engorged.
- D. I will massage my breasts before feeding to stimulate letdown.
Correct Answer: D
Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate letdown, alternating the breasts during feeding, taking a warm shower or applying warm compresses just before feeding, and wearing a supportive well-fitting bra at all times. None of the other options suggest correct measures.
A client has a positive sputum culture for Mycobacterium tuberculosis and is prescribed streptomycin as part of the treatment. The nurse determines that the client is experiencing a toxic effect of the medication when which test result is abnormal?
- A. Vision testing
- B. Hepatic enzymes
- C. Hemoglobin and hematocrit
- D. Blood urea nitrogen (BUN) and creatinine
Correct Answer: D
Rationale: BUN and creatinine are measured during therapy with streptomycin because the medication is nephrotoxic. Vision testing is done during treatment with ethambutol. The client taking isoniazid for tuberculosis is at risk for hepatotoxicity. Hemoglobin and hematocrit are not specifically related to tuberculosis.
Which of the following is appropriate for a client with metabolic alkalosis?
- A. Monitor serum potassium levels
- B. Maintain the client on bed rest
- C. Have the client inhale carbon dioxide using a paper bag
- D. Administer sodium bicarbonate as ordered
Correct Answer: A
Rationale: Metabolic alkalosis can cause hypokalemia, so monitoring serum potassium levels is appropriate. Bed rest is not indicated, inhaling CO2 is for respiratory alkalosis, and sodium bicarbonate would worsen alkalosis.
The nurse walks into a client's room to administer the 9:00 a.m. medications and notices that the client is in an awkward position in bed. What is the nurse's first action?
- A. Ask the client his name.
- B. Check the client's name band.
- C. Straighten the client's pillow behind his back.
- D. Give the client his medications.
Correct Answer: C
Rationale: Repositioning the client first ensures comfort and safety, addressing the immediate issue of the awkward position before administering medications.
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