Nokea
A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?
- A. Experiences nocturia
- B. History of generalized anxiety disorder
- C. Recent exposure to tuberculosis
- D. Reports periodic migraine headaches
Correct Answer: C
Rationale: Recent TB exposure is the priority due to infection risk to others in a semi-private room, requiring immediate isolation precautions.
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A nurse is reinforcing teaching with an older adult client who is postoperative following a transurethral resection of the prostate. Which of the following statements should the nurse include in the teaching?
- A. You should take ibuprofen for discomfort.
- B. You should wait 6 weeks before resuming sexual intercourse.
- C. You may tub bathe until the catheter is removed.
- D. You may drive after 1 week.
- E. Avoid drinking water.
- F. Expect bright red urine indefinitely.
- G. Ignore bladder spasms.
Correct Answer: B
Rationale: Waiting 6 weeks allows healing; ibuprofen may increase bleeding, tub baths risk infection, and driving depends on recovery.
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture
For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Finding: Dyspnea
- A. Dyspnea
- B. Tingling sensation to right foot
- C. Increased pain at incision site
- D. Swelling at incision site
Correct Answer:
Rationale: Dyspnea is a hallmark of fat embolism syndrome due to pulmonary involvement.
A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?
- A. Administer enemas 2 days before the procedure
- B. Do not eat or drink anything except water for 12 hr. before the procedure.
- C. Restrict the diet to clear liquids for 1 to 3 days before the procedure.
- D. Expect the provider to schedule another procedure to remove any polyps
Correct Answer: B
Rationale: A 12-hour fast with only water prepares the colon adequately for a colonoscopy, reflecting standard protocol and client understanding.
A nurse is collecting data from a client who had a bronchoscopy. Which of the following findings should the nurse report to the provider?
- A. Sore throat
- B. Blood pressure 110/78 mm Hg
- C. Presence of gag reflex
- D. Facial edema
Correct Answer: D
Rationale: Post-bronchoscopy, nurses monitor for complications like bleeding, infection, or airway issues. Option A, sore throat, is a common, benign side effect from the scope, not requiring immediate reporting. Option B, blood pressure 110/78 mm Hg, is normal and stable, needing no action. Option C, presence of gag reflex, is reassuring it indicates airway protection is intact post-sedation, a positive sign. Option D, facial edema, is correct to report it's abnormal and could signal an allergic reaction to sedation, airway swelling, or trauma from the procedure, potentially compromising breathing. This finding demands urgent provider evaluation to rule out anaphylaxis or obstruction, aligning with airway management priorities. While sore throat and gag reflex are expected, facial edema deviates from the norm, requiring swift intervention to prevent escalation, making it the critical finding to escalate.
A nurse is reinforcing teaching with a client who is scheduled to undergo a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?
- A. I can have clear liquids up to 3 hours before the procedure.
- B. I can eat as soon as the procedure is completed.
- C. I will receive an injection of radioactive material prior to having the procedure.
- D. I might have blood-tinged sputum after the procedure.
Correct Answer: D
Rationale: Blood-tinged sputum is normal post-bronchoscopy due to airway irritation, showing understanding. Clear liquids stop earlier, eating waits until gag reflex returns, and no radiation is involved.