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A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
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A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the I.V. line. Which nursing intervention protects the client without increasing her increased intracranial pressure (ICP)?
- A. Place her in a jacket restraint.
- B. Wrap her hands in soft "mitten" restraints.
- C. Tuck her arms and hands under the drawsheet.
- D. Apply a wrist restraint to each arm.
Correct Answer: B
Rationale: Soft mitten restraints prevent the client from pulling out the I.V. without restricting circulation or increasing ICP, unlike jacket or wrist restraints, which can cause agitation or pressure. Tucking arms under a drawsheet is unsafe and ineffective.
A client who has had an above-the-knee amputation is to have a dressing change 45 minutes after arriving in the postanesthesia recovery unit. The nurse should:
- A. Elevate the stump.
- B. Reinforce the dressing.
- C. Call the surgeon.
- D. Draw a mark around the site.
Correct Answer: C
Rationale: Excessive bleeding requires the surgeon's evaluation to prevent complications.
Palpation of the skin provides the nurse useful information regarding:
- A. Bruising of the skin.
- B. Color of the skin.
- C. Hair distribution.
- D. Turgor of the skin.
Correct Answer: D
Rationale: Palpation assesses skin turgor, indicating hydration status. Bruising and color are visually assessed, and hair distribution is observed, not palpated.
A client undergoes a laparoscopic cholecystectomy. Which of the following dietary instructions should the nurse give the client immediately after surgery?
- A. You cannot eat or drink anything for 24 hours.
- B. You may resume your normal diet the day after your surgery.
- C. Drink liquids today and eat lightly for a few days.
- D. You can progress from a liquid to a bland diet as tolerated.
Correct Answer: C
Rationale: Post-laparoscopic cholecystectomy, patients typically start with clear liquids and progress to light meals to avoid gastrointestinal stress. Option C is most appropriate. Option A is too restrictive, B is premature, and D is less specific.
Which of the following conditions is the most significant risk factor for the development of type 2 diabetes mellitus?
- A. Cigarette smoking.
- B. High-cholesterol diet.
- C. Obesity.
- D. Hypertension.
Correct Answer: C
Rationale: Obesity is the most significant risk factor for type 2 diabetes due to its impact on insulin resistance.