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A client's job involves working in a warm, dry room, frequently bending and crouching to check the underside of a high-speed press, and wearing eye guards. Given this information, the nurse should assess the client for which of the following?
- A. Muscle aches.
- B. Thirst.
- C. Lethargy.
- D. Orthostatic hypotension.
Correct Answer: D
Rationale: Frequent bending and crouching in a warm, dry environment increases the risk of orthostatic hypotension due to dehydration and positional changes.
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Which symptom indicates a potential complication in a client post-craniotomy?
- A. Mild headache.
- B. Clear nasal drainage.
- C. Stable blood pressure.
- D. Improved appetite.
Correct Answer: B
Rationale: Clear nasal drainage may indicate cerebrospinal fluid leakage, a serious post-craniotomy complication.
After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would be most appropriate to include in a low-fat diet?
- A. Cheese omelet.
- B. Peanut butter.
- C. Ham salad sandwich.
- D. Roast beef.
Correct Answer: D
Rationale: A low-fat diet minimizes gallbladder workload. Roast beef (D) is leaner compared to a cheese omelet (A), peanut butter (B), or ham salad sandwich (C), which are high in fat. Thus, roast beef is the most appropriate choice.
Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply.
- A. Empty and measure indwelling urinary catheter collection bags.
- B. Reposition clients for pain relief.
- C. Teach clients the proper use of the incentive spirometer.
- D. Tell the nurse if clients report they are having pain.
- E. Assess I.V. insertion site for redness.
Correct Answer: A,B,D
Rationale: Unlicensed assistive personnel can empty/measure catheter bags (A), reposition clients (B), and report pain (D). Teaching (C) and assessing IV sites (E) require nursing judgment and are outside their scope.
Which of the following statements would indicate to the nurse that the client who has undergone repair of her nasal septum has understood the discharge instructions?
- A. I should not shower until my packing is removed.
- B. I will take stool softeners and modify my diet to prevent constipation.
- C. Coughing every 2 hours is important to prevent respiratory complications.
- D. It is important to blow my nose each day to remove the dried secretions.
Correct Answer: B
Rationale: Taking stool softeners and modifying the diet to prevent constipation avoids straining (Valsalva's maneuver), which could cause bleeding or complications post-nasal surgery.
Which of the following should the nurse include in the teaching plan for a client with arterial insufficiency to the feet that is being managed conservatively?
- A. Daily lubrication of the feet.
- B. Soaking the feet in warm water.
- C. Applying antiembolism stockings.
- D. Wearing firm, supportive leather shoes.
Correct Answer: A
Rationale: Daily lubrication prevents skin breakdown in arterial insufficiency, improving circulation.