Nokea
A family member asks to take the client, who is on aneurysm precautions, to the unit lounge for 'just a few minutes.' Which concepts should the nurse use when explaining why the client must remain in the room?
- A. A quiet environment promotes more rapid healing of the aneurysm.
- B. Clients with aneurysms need isolation to cope with photosensitivity.
- C. Reduced environmental stimuli are needed to prevent aneurysm rupture.
- D. The client has disorganization of thoughts and feelings and needs reduced activity.
Correct Answer: C
Rationale: Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure and trigger bleeding or rupture of the aneurysm. The aneurysm will not heal more rapidly with reduced stimuli. The client does not need isolation to 'cope' with photosensitivity (although photosensitivity may be a problem). No data indicate that the client has disorganization of thoughts and feelings.
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The nurse is caring for a client receiving chemotherapy. Which precaution is most important?
- A. Use standard precautions.
- B. Wear a gown and gloves.
- C. Place the client in isolation.
- D. Monitor for fever.
Correct Answer: D
Rationale: Monitoring for fever is critical, as chemotherapy increases infection risk due to immunosuppression.
You are working in a community pediatric health clinic. Which expected life transition should you apply into your practice for these pediatric clients as you are caring for pediatric clients of all ages?
- A. Pregnancy
- B. Puberty
- C. Childhood immunizations
- D. Separation anxiety
Correct Answer: B
Rationale: Puberty is a significant life transition for pediatric clients, particularly adolescents, and is relevant across the age range in a pediatric clinic. It involves physical, emotional, and social changes that nurses should consider in their practice.
A client with a hip fracture is scheduled for surgery. Which preoperative teaching should the nurse include?
- A. Avoid coughing post-surgery
- B. Expect to ambulate immediately
- C. Use of incentive spirometry
- D. Limit fluid intake
Correct Answer: C
Rationale: Incentive spirometry prevents postoperative pulmonary complications like atelectasis, critical for a client with limited mobility post-hip surgery.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after inhalation.
- C. Take the inhaler with meals.
- D. Stop the inhaler if dizziness occurs.
Correct Answer: B
Rationale: Rinsing the mouth after tiotropium inhalation prevents oral thrush.
A client is admitted to the hospital after sustaining a fall from a roof. The client has multiple lacerations and a right leg fracture, which has been treated with a plaster cast. How should the nurse position the client's leg to promote optimal circulation?
- A. Flat or a level position
- B. Flat for 3 hours and elevated for 1 hour
- C. Elevated for 3 hours, and then flat for 1 hour
- D. Elevated on pillows continuously for 24 to 48 hours
Correct Answer: D
Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. The other options are not part of standard positioning of the newly casted extremity.