Nokea
A client with osteoarthritis will undergo an arthrocentesis on his painful edematous knee. What should be included in the nursing plan of care? Select all that apply.
- A. Explain the procedure.
- B. Administer preoperative medication 1 hour before surgery.
- C. Instruct the client to immobilize the knee for 2 days after the surgery.
- D. Assess the site for bleeding.
- E. Offer pain medication.
Correct Answer: A,D,E
Rationale: Explaining the procedure You are missing 30 questions, assessing for bleeding, and offering pain medication are key. Arthrocentesis is a minor procedure, not surgery, and immobilization for 2 days is not typically required.
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A client with leukemia is admitted with a white blood cell count of 2,000/mm³ and a fever of 101.8°F (38.8°C). The nurse should initiate:
- A. Contact precautions.
- B. Reverse isolation.
- C. Standard precautions.
- D. Droplet precautions.
Correct Answer: B
Rationale: A low white blood cell count (2,000/mm³) with fever indicates neutropenia and high infection risk, necessitating reverse isolation to protect the client from pathogens.
The nurse is preparing a community education program about preventing hepatitis B infection. Which of the following would be appropriate to incorporate into the teaching plan?
- A. Hepatitis B is relatively uncommon among college students.
- B. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B.
- C. Good personal hygiene habits are most effective at preventing the spread of hepatitis B.
- D. The use of a condom is advised for sexual intercourse.
Correct Answer: D
Rationale: Condom use (D) prevents hepatitis B transmission via sexual contact. Hepatitis B is not uncommon in college students (A). Alcohol (B) is unrelated to hepatitis B transmission. Hygiene (C) is less effective than barrier protection.
The nurse is teaching the client how to care for her ileostomy. The client asks the nurse how long she can wear her pouch before changing it. The nurse responds:
- A. The pouch is changed only when it leaks.
- B. You can wear the pouch for about 4 to 7 days.
- C. You can wear the pouch for about 4 to 7 days.
- D. It depends on your activity level and your diet.
Correct Answer: B
Rationale: An ileostomy pouch is typically worn for 4 to 7 days unless it leaks or causes skin irritation, providing a standard guideline for routine changes. Activity level and diet may influence output but are not the primary determinants for pouch change frequency. CN: Physiological adaptation; CL: Synthesize
After a subtotal gastrectomy, the nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?
- A. Dark brown.
- B. Bile green.
- C. Bright red.
- D. Cloudy white.
Correct Answer: C
Rationale: Nasogastric tube drainage is typically bright red for 12 to 24 hours post-gastrectomy due to surgical bleeding, gradually changing as bleeding subsides.
As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which of the following statements by the client indicates she understands her current ability?
- A. I will be able to have sexual intercourse until the urinary catheter is removed.'
- B. I can participate in sexual activity but might not experience orgasm.'
- C. I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay.'
- D. I should be able to participate in sexual activity, but I will be infertile.'
Correct Answer: B
Rationale: Quadriplegia may impair sensation and orgasm but does not preclude sexual activity, which the client correctly understands.