Nokea
A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Have the client sign an against medical advice form.
- C. Tell the client that the surgeon will prescribe restraints if they try to leave.
- D. Explain to the client that they cannot leave until the surgeon discharges them.
Correct Answer: B
Rationale: An AMA form documents the client's informed decision to leave against advice.
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A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clamp the tube when I go for a walk.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will apply antiseptic ointment to the tip of my penis.
Correct Answer: B
Rationale: Keeping the bag below the waist prevents urine backflow and infection.
Nurses' Notes
Diagnostic Results
Day 1:
1000:
A peripherally inserted central catheter (PICC) is inserted into left arm. Dressing dry and intact. Bilateral breath sounds clear and present throughout.
1200:
Parenteral nutrition started through PICC line infusing at 75 mL/hr.
Day 3:
0800:
Client is lethargic and reports thirst and frequent urination. Bilateral breath sounds clear and present throughout.
A nurse is reviewing the medical record of a client who has a paralytic ileus.
Select words from the choices below to fill in each blank in the following sentence:
The findings in the client's medical record indicate----and----.
- A. Dehydration
- B. Pneumothorax
- C. Hyperglycemia
- D. Infection
- E. Electrolyte Imbalance
- F. Hypoglycemia
Correct Answer: A, C
Rationale: A: Thirst and urination suggest dehydration. C: Lethargy and polyuria indicate hyperglycemia from parenteral nutrition.
A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
- A. Hyperthermia
- B. Urticaria
- C. Dyspnea
- D. Headache
Correct Answer: C
Rationale: Dyspnea is a critical sign of a transfusion reaction, requiring immediate reporting.
A nurse is reinforcing teaching with a client who is about to start using a standard walker. Which of the following statements by the client indicates an understanding of the instructions?
- A. I'll keep the height of my walker adjusted so lean slightly forward
- B. I'll slide the walker and move it about a foot in front of me
- C. I'll move the walker and my stronger leg ahead at the same time
- D. I'll keep my elbows slightly bent when I grasp the walker
Correct Answer: D
Rationale: Slightly bent elbows ensure proper posture and control with a walker.
A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the specimen in a clean specimen cup.
- B. Clamp the catheter tubing below the needleless port.
- C. Clamp the catheter tubing for 60 min.
- D. Remove 45 mL of urine from the catheter with a syringe.
Correct Answer: B
Rationale: Clamping below the port allows fresh urine to collect for an accurate culture.