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A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following actions should the nurse take?
- A. Monitor the client for neck swelling.
- B. Instruct the client to resume a high-iodine diet.
- C. Apply a heating pad to the surgical site.
- D. Encourage the client to speak loudly to test vocal cords.
Correct Answer: A
Rationale: Neck swelling post-thyroidectomy could indicate hematoma or edema, requiring monitoring. High-iodine diets, heating pads, and loud speaking aren't appropriate.
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A nurse is reinforcing teaching with a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can take aspirin for a headache.
- B. I might need to have my blood tested regularly.
- C. I should increase my intake of green leafy vegetables.
- D. I can stop taking this medication once my clot dissolves.
Correct Answer: B
Rationale: Warfarin requires regular INR monitoring to ensure therapeutic levels. Aspirin increases bleeding risk, leafy greens affect efficacy, and stopping risks recurrence.
A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?
- A. Tell the client she should discuss this decision with her family.
- B. Support the client's decision to stop the treatment.
- C. Discuss alternative treatment methods with the client.
- D. Ask the facility chaplain to visit the client.
Correct Answer: B
Rationale: Supporting the client's decision respects autonomy, a core ethical principle. Discussing with family, alternatives, or involving a chaplain are secondary to honoring the client's choice.
A nurse is caring for a client who is postoperative following a cesarean birth. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate within 24 hr.
- B. Instruct the client to avoid coughing.
- C. Apply a cold pack to the incision site.
- D. Administer a laxative every 2 hr.
Correct Answer: A
Rationale: Ambulation within 24 hours prevents thromboembolism and aids recovery. Coughing supports lung function, cold packs aren't standard, and laxatives aren't given that frequently.
A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?
- A. Justice
- B. Autonomy
- C. Veracity
- D. Beneficence
Correct Answer: C
Rationale: Veracity involves truthful communication. By honestly discussing medication side effects, the nurse upholds this principle, supporting informed decision-making.
A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?
- A. Observe the client during and after meals.
- B. Suggest that the client assist with meal planning.
- C. Instruct the client about effective coping strategies.
- D. Refer the client to a support group for clients who have eating disorders.
Correct Answer: A
Rationale: Observing during and after meals monitors for purging behaviors, a priority for safety in bulimia. Meal planning, coping strategies, and support groups follow after ensuring immediate safety.