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A nurse is caring for a client who is postoperative following a below-the-knee amputation. Which of the following statements made by the client indicates acceptance of their altered body image?
- A. I would like to meet with another client who has had an amputation.
- B. I would rather not look at my stump during a dressing change.
- C. I am glad that I no longer have to deal with my infected leg.
- D. I understand that I will be unable to return to my job.
Correct Answer: A
Rationale: The correct answer is A: "I would like to meet with another client who has had an amputation." This statement indicates acceptance of the altered body image as the client is actively seeking connection with others who have gone through a similar experience. By expressing a desire to meet someone with a similar amputation, the client is acknowledging and normalizing their own situation, showing acceptance and readiness to engage in discussions about their body image.
Summary of why other choices are incorrect:
B: "I would rather not look at my stump during a dressing change." - This statement suggests avoidance and discomfort with the amputation, indicating a lack of acceptance.
C: "I am glad that I no longer have to deal with my infected leg." - While this statement may indicate relief from a health issue, it does not necessarily demonstrate acceptance of the altered body image.
D: "I understand that I will be unable to return to my job." - This statement reflects resignation to a limitation but does not directly address body
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A nurse is caring for a client receiving TPN. Which of the following actions should the nurse take?
- A. Monitor serum blood glucose during infusion.
- B. Obtain the client's weight daily.
- C. Infuse 0.9% sodium chloride if the solution is not available.
- D. Verify the solution with another RN prior to infusion.
Correct Answer: A
Rationale: The correct answer is A: Monitor serum blood glucose during infusion. This is crucial because TPN (total parenteral nutrition) is a high concentration of glucose and can lead to hyperglycemia. Regular monitoring helps in detecting and managing any glucose fluctuations promptly. Choice B is incorrect as daily weight is essential but not the priority when compared to monitoring glucose. Choice C is incorrect as infusing 0.9% sodium chloride as an alternative can lead to incompatible solutions and cause harm. Choice D is incorrect because verifying the solution with another RN is important for safety but does not address the immediate need for glucose monitoring.
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Abnormal vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Abnormal vaginal bleeding. This is a possible indication of cervical cancer because it can be a symptom of cervical dysplasia or cervical cancer. Bleeding between periods, after intercourse, or post-menopausal bleeding may indicate cervical cancer. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typically associated with cervical cancer. Diarrhea and urinary hesitancy are more commonly linked to gastrointestinal or urinary issues, while unexplained weight gain may be indicative of hormonal imbalances or other health conditions unrelated to cervical cancer.
A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?
- A. Teach the client how to self-medicate using the PCA device.
- B. Encourage family members to press the PCA button for the client.
- C. Monitor the client's respiratory status every 4 hr.
- D. Administer an oral opioid for breakthrough pain.
Correct Answer: A
Rationale: The correct answer is A: Teach the client how to self-medicate using the PCA device. This is important because it empowers the client to control their pain management while ensuring safety. Teaching the client how to use the PCA device helps promote autonomy and ensures that the client is receiving the appropriate dose of medication as prescribed. Encouraging family members to press the button (B) may lead to inappropriate dosing and compromise the client's safety. Monitoring respiratory status (C) is important but should be done more frequently, such as every hour, as respiratory depression can occur with morphine use. Administering an oral opioid for breakthrough pain (D) may not be necessary if the client is able to self-medicate effectively with the PCA device.
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Pistolate
Correct Answer: B
Rationale: The correct answer is B: Infection. The kinked IV tubing and the urinary catheter bag lying next to the client in bed can lead to contamination of the catheter system, increasing the risk of a urinary tract infection. The kinked tubing can cause backup of urine, leading to bacterial growth, while the catheter bag being on the bed can introduce pathogens to the catheter. Infections can result in serious complications for the client if not addressed promptly. The other choices, A: Neurogenic bladder, C: Skin breakdown, and D: Pistolate, are not directly related to the scenario presented and do not pose an immediate risk based on the information provided.
A nurse is continuing to care for a client who is postoperative following surgical removal of an abdominal abscess. Which of the following actions should the nurse take?
- A. Obtain vital signs every 30 minutes.
- B. Elevate the client in a semi-Fowler's position.
- C. Apply oxygen.
- D. Monitor the client's level of consciousness.
Correct Answer: B
Rationale: The correct answer is B: Elevate the client in a semi-Fowler's position. Elevating the client in a semi-Fowler's position helps promote optimal lung expansion and ventilation, reducing the risk of postoperative complications such as atelectasis and pneumonia. This position also aids in preventing aspiration and promotes comfort.
Choice A: Obtaining vital signs every 30 minutes is important postoperatively, but it is not the most immediate action needed in this case.
Choice C: Applying oxygen may be necessary depending on the client's oxygen saturation levels, but it is not the most essential action to take at this point.
Choice D: Monitoring the client's level of consciousness is important, but it is not as critical as positioning the client correctly to prevent respiratory complications.