Nokea
A nurse is caring for a client at home on hospice care for terminal renal cancer. People are calling the nurse to inquire about the client's condition. The nurse should tell the callers:
- A. Please call the oncologist.
- B. The client is in a coma now.
- C. Please call the client's sister.
- D. The client is not expected to live much longer.
Correct Answer: C
Rationale: Directing callers to the client's sister respects privacy and ensures consistent communication, aligning with the family's preferences in hospice care.
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A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?
- A. Increase daily fluid intake to at least 2 to 3 L.
- B. Strain urine at home regularly.
- C. Eliminate dairy products from the diet.
- D. Follow measures to alkalinize the urine.
Correct Answer: A,B
Rationale: High fluid intake (2-3 L) prevents stone recurrence, and straining urine monitors for stone passage. Dairy restriction or urine alkalinization depends on stone type.
Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis?
- A. Rolling the client onto the side.
- B. Sliding the client to move up in bed.
- C. Lifting the client when moving the client up in bed.
- D. Having the client help lift off the bed using a trapeze.
Correct Answer: B
Rationale: Sliding the client can cause shear injuries to the skin, especially in hemiparalysis with reduced sensation. Rolling, lifting, or using a trapeze (if feasible) are safer techniques.
Which of the following areas is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer?
- A. The support available to assist the client at home.
- B. The distance the client lives from the hospital.
- C. The client's ability to do home blood pressure monitoring.
- D. The client's knowledge of the causes of lung cancer.
Correct Answer: A
Rationale: Home support is critical post-lobectomy to assist with recovery, medication adherence, and monitoring complications. Distance from the hospital, blood pressure monitoring, and knowledge of cancer causes are less immediate priorities.
A client 24 hours post-appendectomy reports sudden sharp abdominal pain and a fever of 101.2°F (38.4°C). The nurse's first action should be:
- A. Administer an antipyretic.
- B. Notify the surgeon.
- C. Encourage ambulation.
- D. Apply a warm compress.
Correct Answer: B
Rationale: Sudden sharp pain and fever post-appendectomy suggest a complication like abscess or peritonitis. Notifying the surgeon ensures prompt evaluation and intervention.
The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet?
- A. Hamburger, salad, and milkshake.
- B. Baked liver, green beans, and coffee.
- C. Spaghetti with tomato sauce, salad, and coffee.
- D. Fried chicken, green beans, and skim milk.
Correct Answer: C
Rationale: Spaghetti with tomato sauce, salad, and coffee is low in cholesterol, unlike hamburger, liver, or fried chicken, which contain higher cholesterol or saturated fats.