Nokea
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
- A. Keep the knee elevated above the heart at all times.
- B. Avoid physical therapy for 2 weeks.
- C. Apply ice to the affected area.
- D. Limit fluid intake to reduce swelling.
Correct Answer: C
Rationale: The correct answer is C: Apply ice to the affected area. Ice application helps reduce swelling and pain post-surgery. Keeping the knee elevated above the heart (A) is important, but not at all times as it can lead to other issues like blood pooling. Avoiding physical therapy for 2 weeks (B) is incorrect as early mobilization is crucial for recovery. Limiting fluid intake (D) is not recommended as hydration is essential for healing.
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A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will be sure to take the albuterol before taking the cromolyn.
- B. I will take both medications at the same time.
- C. I will take the cromolyn before taking albuterol.
- D. I will take the medications in any order.
Correct Answer: A
Rationale: The correct answer is A: "I will be sure to take the albuterol before taking the cromolyn." This is because albuterol is a bronchodilator that helps to open up the airways quickly, providing immediate relief during an asthma attack. Cromolyn, on the other hand, is a mast cell stabilizer that helps to prevent asthma attacks but does not provide immediate relief. Taking albuterol first allows for quick relief, followed by cromolyn for long-term prevention.
Choice B is incorrect as taking both medications at the same time may not allow for the full effectiveness of each drug. Choice C is incorrect as cromolyn should be taken before albuterol to allow time for it to take effect. Choice D is incorrect as there is a specific order in which these medications should be taken for optimal results.
A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?
- A. Check the results of the client's most recent CBC
- B. Administer a blood transfusion
- C. Offer the client a stimulant medication
- D. Advise the client to reduce physical activity
Correct Answer: A
Rationale: The correct answer is A: Check the results of the client's most recent CBC. Fatigue is a common side effect of cisplatin, which can cause bone marrow suppression leading to anemia. Checking the CBC will help determine if the client is experiencing anemia, which can be managed with appropriate interventions. Administering a blood transfusion (B) should not be done without confirming the need through lab results. Offering a stimulant medication (C) may mask the underlying cause of fatigue. Advising the client to reduce physical activity (D) may not address the root cause of the fatigue.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
- A. A room with air exhaust directly to the outdoor environment
- B. A room with a ventilated ceiling fan
- C. A room with a window and curtains that close
- D. A shared room with other tuberculosis clients
Correct Answer: A
Rationale: The correct answer is A: A room with air exhaust directly to the outdoor environment. This is the appropriate room assignment for a client with active tuberculosis because it helps prevent the spread of airborne infectious particles. The air exhaust system ensures that contaminated air is not recirculated within the unit, reducing the risk of transmission to other patients and staff.
Choice B (A room with a ventilated ceiling fan) is incorrect because a ceiling fan does not provide sufficient ventilation to prevent the spread of tuberculosis.
Choice C (A room with a window and curtains that close) is also incorrect as it does not address the need for proper ventilation and containment of infectious particles.
Choice D (A shared room with other tuberculosis clients) is clearly incorrect as it would increase the risk of transmission among the clients.
In summary, the correct room assignment for a client with active tuberculosis should prioritize containment and ventilation to minimize the risk of spreading the infection to others.
A nurse works with an AP assigned to bathe a client with herpes zoster. The AP asks if it is contagious. What should the nurse say?
- A. Herpes zoster is not contagious to people who have had chickenpox.
- B. Herpes zoster spreads through the air.
- C. Herpes zoster is highly contagious to everyone.
- D. Herpes zoster only spreads through blood contact.
Correct Answer: A
Rationale: The correct answer is A. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. Individuals who have had chickenpox in the past are not at risk of getting shingles from someone with herpes zoster. The virus is not transmitted through the air (choice B) or through blood contact only (choice D). It is not highly contagious to everyone (choice C). By explaining to the AP that herpes zoster is not contagious to individuals who have had chickenpox, the nurse provides accurate information and helps alleviate concerns about the spread of the virus.
A nurse teaches a client with vulvodynia about self-care. What statement indicates understanding?
- A. I should use scented soaps.
- B. I should avoid the use of any lubricants.
- C. I should wear tight synthetic underwear.
- D. I should use hot baths frequently.
Correct Answer: B
Rationale: The correct answer is B. Clients with vulvodynia should avoid the use of any lubricants to prevent irritation and exacerbation of symptoms. Lubricants can contain chemicals or fragrances that can further irritate the sensitive skin in the vulvar area. Choosing products specifically designed for sensitive skin or recommended by a healthcare provider is crucial. Using lubricants can worsen symptoms and discomfort.
Avoiding scented soaps (choice A) is important as well because fragrances can also irritate the vulvar area. Wearing tight synthetic underwear (choice C) can trap moisture and heat, leading to increased irritation. Using hot baths frequently (choice D) can also worsen symptoms by further irritating the sensitive skin.