Nokea
A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, 'Why does she have this tube inserted in her hip?' Which of the following responses would be best?
- A. The tube helps us to detect a wound infection early on.'
- B. This way we won't have to irrigate the wound.'
- C. Fluid won't be allowed to accumulate at the site.'
- D. We have a way to administer antibiotics into the wound.'
Correct Answer: C
Rationale: The drainage tube prevents fluid accumulation, reducing infection risk and promoting healing.
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To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the nurse should instruct the client to:
- A. Rinse the mouth with saline solution.
- B. Perform frequent toothbrushing.
- C. Clean the teeth with an electric toothbrush.
- D. Floss the teeth thoroughly.
Correct Answer: A
Rationale: Saline mouth rinses are gentle and safe post-transsphenoidal hypophysectomy, avoiding irritation to the surgical site.
A nurse is assessing a 42-year-old client who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm³ and has petechiae on the lower extremities. The nurse should advise the client to:
- A. Increase the amount of iron in the client's diet.
- B. Apply lotion to the lower extremities.
- C. Elevate the legs.
- D. Consult the oncologist.
Correct Answer: D
Rationale: A platelet count of 22,000/mm³ with petechiae indicates severe thrombocytopenia, requiring urgent consultation with the oncologist for potential platelet transfusion or treatment adjustment.
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
- A. Anxiety related to the presence of a urinary diversion.
- B. Deficient knowledge about how to care for the urinary diversion.
- C. Low self-esteem related to feelings of worthlessness.
- D. Unstuffed body image related to creation of a urinary diversion.
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
The nurse administers a bolus tube feeding to a client with cancer. Which of the following nursing interventions is most appropriate to decrease the risk of aspiration?
- A. Place the client on bed rest with the head of the bed elevated to 60 degrees for 2 hours.
- B. Place the client on the left side with the head of the bed at 45 degrees for 15 minutes.
- C. Assist the client out of bed to sit upright in a chair for 1 hour.
- D. Ask the client to rest in bed with the head of the bed elevated to 30 degrees for 20 minutes.
Correct Answer: C
Rationale: Sitting upright in a chair for 1 hour after a bolus tube feeding minimizes aspiration risk by promoting gastric emptying and reducing reflux.
Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg?
- A. Give the client a warming blanket.
- B. Administer low-dose barbiturates.
- C. Encourage the client to hyperventilate.
- D. Restrict fluids.
Correct Answer: B
Rationale: Low-dose barbiturates can reduce cerebral metabolism and ICP, making them appropriate in some cases under medical supervision. Warming blankets increase metabolic demand, hyperventilation is no longer routinely recommended due to risks of cerebral vasoconstriction, and fluid restriction is not standard for ICP management unless specifically indicated.