Nokea
A client who has had a lumbar laminectomy with a spinal fusion is sitting in a chair. In which position are his feet if he is complying with his postoperative instructions?
- A. On the floor with the feet flat.
- B. On a low footstool.
- C. In any comfortable position with legs uncrossed.
- D. On a high footstool so the feet are level with the chair seat.
Correct Answer: A
Rationale: Feet flat on the floor maintain neutral spine alignment, reducing strain on the surgical site.
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A client has a Jackson-Pratt drainage tube in place the first day after surgical repair of a ruptured diverticulum. The client asks the nurse the purpose of the drain. What is the nurse's best response?
- A. œThe drainage tube is used to prevent infection in the peritoneal cavity.'
- B. œThe drainage tube is used to prevent bleeding into the peritoneal cavity.'
- C. œThe drainage tube is used to prevent pressure on on the bladder.'
- D. œThe drainage tube is used to prevent pressure on the gallbladder.'
Correct Answer: A
Rationale: A Jackson-Pratt drain removes fluid and blood from the surgical site, preventing infection in the peritoneal cavity by reducing fluid accumulation post-diverticulum repair.
The client is diagnosed in the emergency department with a detached retina in the right eye. The nurse should do which of the following first?
- A. Apply compresses to the eye.
- B. Administer analgesics to reduce pain.
- C. Remove all bed pillows.
- D. Promote measures that limit mobility.
Correct Answer: D
Rationale: Limiting mobility is the priority to prevent further detachment of the retina by reducing eye movement and strain until surgical intervention can be performed.
College freshman are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on:
- A. Water sanitation.
- B. Single dormitory rooms.
- C. Vaccine for hepatitis B.
- D. Safe sexual practices.
Correct Answer: D
Rationale: Hepatitis B is transmitted via blood and body fluids, so safe sexual practices (D) are critical for prevention. Water sanitation (A) is more relevant for hepatitis A. Single rooms (B) are unnecessary. The vaccine (C) is preventive but not the focus of behavioral instruction.
A 52-year-old client is scheduled for a total abdominal hysterectomy for cervical cancer. The nurse is preparing preoperative teaching. Which of the following should be included in the teaching plan to address potential changes in sexuality?
- A. Sexual intercourse will not be possible after surgery.
- B. Vaginal dryness may occur, and water-soluble lubricants can help.
- C. Menopausal symptoms will not occur if ovaries are preserved.
- D. Sexual desire will remain unchanged after surgery.
Correct Answer: B
Rationale: Vaginal dryness is a common side effect after hysterectomy due to changes in vaginal tissue and potential hormonal shifts, even if ovaries are preserved. Teaching about water-soluble lubricants helps the client prepare for and manage this change.
Which of the following interventions will be most effective in improving transcultural communications with the client?
- A. Use touch to show concern and caring for the client.
- B. Focus attention on verbal communication skills only.
- C. Establish a rapport and listen to their concerns.
- D. Maintain eye contact at all times.
Correct Answer: C
Rationale: Establishing rapport and listening to concerns fosters trust and understanding, which are essential for effective transcultural communication.