Nokea
A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. Which of the following discharge instructions would be appropriate for the client?
- A. Avoid activities that elicit the Valsalva maneuver.
- B. Take aspirin to control nasal discomfort.
- C. Avoid brushing the teeth until the nasal packing is removed.
- D. Apply heat to the nasal area to control swelling.
Correct Answer: A
Rationale: Avoiding the Valsalva maneuver (e.g., straining) prevents increased pressure that could dislodge packing or cause bleeding. Aspirin increases bleeding risk. Tooth brushing is safe with care. Heat may increase swelling; cold is preferred.
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The nurse is preparing to administer a prescribed medication to a client. The nurse should take which initial action?
- A. Verify the client's full name and date of birth
- B. Ask about any medication allergies
- C. Review the client's vital signs
- D. Review medications and potential interactions
Correct Answer: A
Rationale: Verifying client identity using two identifiers is the initial step to ensure safe medication administration.
The nurse is caring for a client with a new colostomy and notices the client is reluctant to participate in self-care. Which intervention should the nurse implement first?
- A. Teach the client's family to perform colostomy care.
- B. Refer the client to a support group.
- C. Assess the client's barriers to self-care.
- D. Provide written instructions for colostomy care.
Correct Answer: C
Rationale: Assessing the client's barriers to self-care is the first step to understand and address their reluctance, enabling tailored interventions. Teaching family, referring to a support group, or providing instructions are secondary after identifying the underlying issues. CN: Psychosocial adaptation; CL: Synthesize
A client with a surgical wound reports itching around the incision site on postoperative day 5. The nurse should:
- A. Apply an antihistamine cream.
- B. Assess the wound for signs of infection.
- C. Instruct the client to avoid scratching.
- D. Clean the wound with alcohol.
Correct Answer: C
Rationale: Itching is common during healing, but scratching can disrupt the incision. Instructing the client to avoid scratching prevents wound dehiscence while further assessment can rule out infection.
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation?
- A. An obstruction is present in the chest tube.
- B. The client is developing subcutaneous emphysema.
- C. The chest tube system is functioning properly.
- D. There is a leak in the chest tube system.
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates a patent chest tube system, reflecting pleural pressure changes. Obstruction, emphysema, or leaks would show different signs.
A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) within the past hour. The nurse should ask the outgoing RN to do which of the following actions?
- A. Validate with the outgoing RN that morphine 10 mg (IM) had been administered.
- B. Assess the client for manifestations of pain.
- C. Check the medication documentation as to when morphine 10 mg (IM) was dispensed and to whom.
- D. Check to ascertain if any discrepancy had been documented with accompanying reason/s.
Correct Answer: A
Rationale: Validating with the outgoing RN confirms the morphine administration, ensuring safe timing of the next dose and preventing overdose.