Nokea
A client with diabetes mellitus comes to the clinic for a regular 3-month follow-up appointment. The nurse notes several small bandages covering cuts on the client's hands. The client says, 'I'm so clumsy. I'm always cutting my finger cooking or burning myself on the iron.' Which of the following responses by the nurse would be most appropriate?
- A. Soak small wounds in isopropyl alcohol.'
- B. Keep all cuts clean and covered.'
- C. Why don't you have your children do the cooking and ironing?'
- D. You really should be fine as long as you take your daily medication.'
Correct Answer: B
Rationale: Keeping cuts clean and covered prevents infection, a significant risk in diabetes due to poor wound healing.
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The client is to take nothing by mouth after 4 a.m. The nurse recognizes that the client has deficient knowledge when he states that he:
- A. Ate a gelatin dessert at 3:30 a.m.
- B. Brushed his teeth at 4:00 a.m. but did not swallow.
- C. Held a cold washcloth against his lips.
- D. Smoked a cigarette at 6:00 a.m.
Correct Answer: D
Rationale: Smoking after 4 a.m. violates the nothing-by-mouth (NPO) order, as it introduces substances into the body and can affect anesthesia safety. The other actions either comply with NPO (brushing teeth without swallowing, holding a washcloth) or occurred before the cutoff (gelatin at 3:30 a.m.).
A client post-cystoscopy is discharged. The nurse should instruct to:
- A. Resume normal activity.
- B. Avoid fluids for 24 hours.
- C. Expect blue urine.
- D. Take antibiotics for a week.
Correct Answer: A
Rationale: Normal activity can resume post-cystoscopy unless complications arise.
At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
- A. Report the 24-hour drainage amount at 12. Clamp the T-tube.
- B. Evaluate the tube for patency.
- C. Irrigate the T-tube.
- D. Continue to monitor the drainage.
Correct Answer: C
Rationale: The T-tube should drain approximately 300 to 500 mL in the fi rst 24 hours and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 8 a.m., the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without an order.
A nurse is teaching a client about cystoscopy preparation. What instruction should be included?
- A. Fast for 8 hours before the procedure.
- B. Drink plenty of water before the test.
- C. Expect to stay overnight in the hospital.
- D. Empty the bladder before the procedure.
Correct Answer: D
Rationale: Emptying the bladder ensures a clear view during cystoscopy and reduces discomfort.
Postoperative nursing care for a client after an appendectomy should include which of the following?
- A. Administering sitz baths four times a day.
- B. Noting the first bowel movement after surgery.
- C. Limiting the client's activity to bathroom privileges.
- D. Measuring abdominal girth every 2 hours.
Correct Answer: B
Rationale: Noting the first bowel movement after an appendectomy is important to confirm the return of bowel function. Sitz baths, limited activity, or measuring girth are not standard post-appendectomy care. CN: Physiological adaptation; CL: Synthesize