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A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the unlicensed assistive personnel (UAP) to do during postmortem care? Select all that apply.
- A. Remove all tubes and I.V. lines.
- B. Cover the body with a sheet.
- C. Notify the family.
- D. Transport the body to the morgue.
- E. Notify the chaplain.
Correct Answer: B,D
Rationale: UAP can cover the body and transport it to the morgue. Removing tubes may be restricted due to forensic needs, and notifying family or chaplain is typically a nurse's responsibility.
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A client with an ileal conduit reports a bulging stoma. The nurse suspects:
- A. Stoma retraction.
- B. Parastomal hernia.
- C. Stoma ischemia.
- D. Infection.
Correct Answer: B
Rationale: A bulging stoma suggests a parastomal hernia, a complication requiring evaluation.
What areas of education should the nurse provide the narrowness to a factory making the cause respiratory irritation to reduce the risk of laryngeal cancer? Select all that apply.
- A. Smoking cessation concurrent with counseling.
- B. HEPA filter use in the home.
- C. Limiting alcohol use.
- D. Brushing teeth after every meal.
- E. Raising the voice to be heard over the noise in the factory.
Correct Answer: A,C
Rationale: Smoking and excessive alcohol use are major risk factors for laryngeal cancer; cessation and moderation reduce risk. HEPA filters address general air quality but not specific carcinogens. Brushing teeth and raising the voice are unrelated to laryngeal cancer risk.
The nurse should ask all clients age 65 or older who are having surgery which question?
- A. Do you have Medicare Part A to help pay for the hospital reimbursement?'
- B. œDo you have an advance directive such as a health care proxy or living will?'
- C. œDo you have extra coverage to help pay for medications?'
- D. œDo you have Medicare Part B to help pay for your expenses?'
Correct Answer: B
Rationale: Asking about an advance directive ensures the client's wishes are documented, especially critical for older adults facing surgical risks, to guide care in case of incapacity.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
- A. Hyperalbuminemia.
- B. Thrombocytopenia.
- C. Hypokalemia.
- D. Hypercalcemia.
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eyedrops. The rationale that supports applying pressure is that it:
- A. Prevents the medication from entering the tear duct.
- B. Prevents the drug from running down the client's face.
- C. Allows the sensitive cornea to adjust to the medication.
- D. Facilitates distribution of the medication over the eye surface.
Correct Answer: A
Rationale: Applying pressure at the inner canthus (punctal occlusion) prevents the medication from draining into the tear duct, which could lead to systemic absorption or reduced effectiveness of the eye drops.