Nokea
A client with an ileal conduit asks how to reduce pouch odor. The nurse suggests:
- A. Avoiding broccoli.
- B. Using bleach to clean the pouch.
- C. Drinking less water.
- D. Applying powder to the stoma.
Correct Answer: A
Rationale: Odor-producing foods like broccoli should be avoided to minimize pouch odor.
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A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condition. The most effective way to determine the effectiveness of CPR is noting whether the:
- A. Pulse rate is normal.
- B. Pupils are reacting to light.
- C. Mucous membranes are pink.
- D. Systolic blood pressure is at least 80 mm Hg.
Correct Answer: D
Rationale: A systolic blood pressure of at least 80 mm Hg indicates effective CPR, as it reflects adequate circulation and perfusion.
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
- A. Back at the level of the client's scapula.
- B. Back and head that are high.
- C. Seat that is lower than normal.
- D. Seat with firm cushions.
- E. Chair controlled by client's breath.
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.
Twenty-four hours after a bone marrow aspiration, the nurse evaluates which of the following as an appropriate client outcome?
- A. The client maintains bed rest.
- B. There is redness and swelling at the aspiration site.
- C. The client requests morphine sulfate for pain.
- D. There is no bleeding at the aspiration site.
Correct Answer: D
Rationale: A successful outcome 24 hours after bone marrow aspiration is no bleeding at the site, indicating proper healing and no complications. Bed rest is not required, redness/swelling suggests infection, and morphine requests indicate uncontrolled pain, which is not expected.
A client post-ureteroscopy reports burning on urination. The nurse should:
- A. Encourage fluids.
- B. Administer antibiotics.
- C. Apply a heating pad.
- D. Notify the physician.
Correct Answer: A
Rationale: Burning is common post-ureteroscopy; fluids dilute urine, reducing irritation.
How often should the postoperative client's temperature be assessed during the first 24 hours after surgery?
- A. Every 2 hours.
- B. Every 4 hours.
- C. Every 6 hours.
- D. Every 8 hours.
Correct Answer: B
Rationale: Assessing temperature every 4 hours in the first 24 hours detects fever early, indicating potential infection or other complications.