Nokea
A nurse is completing the health history for a client with the patient taking echinacea for a health care. The client asks, 'Why Isn't this helping me feel better?' Which of the following responses by the nurse would be the most accurate?
- A. There is limited information as to the effectiveness of herbal products.
- B. Antibiotics are the agents needed to treat a head cold.
- C. The head cold should be gone within the month.
- D. Combining herbal products with prescription antiviral medications is sure to help you.
Correct Answer: A
Rationale: At this time, there is no strong research evidence to warrant recommendations of herbal products for management of colds; further study is needed to show evidence of therapeutic effects and indications. Antibiotics are effective against bacteria; the head cold may have a viral cause. An uncomplicated upper respiratory tract infection subsides within 2 to 3 weeks. There may be a drug-drug interaction with herbal products and prescriptions.
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The nurse instructs the client on health maintenance activities to help control symptoms from her hiatal hernia. Which of the following statements would indicate that the client has understood the instructions?
- A. I'll avoid lying down after a meal.'
- B. I can still enjoy my potato chips and cola at bedtime.'
- C. I wish I didn't have to give up swimming.'
- D. If I wear a girdle, I'll have more support for my stomach.'
Correct Answer: A
Rationale: Avoiding lying down after meals prevents reflux, indicating the client understands hiatal hernia management. The other statements are incorrect or irrelevant.
A 32-year-old female meets with the nurse on her first office visit since undergoing a left mastectomy. When asked how she is doing, the woman says her appetite is still not good, she is not getting much sleep because she doesn't go to bed until her husband is asleep, and she is really anxious to get back to work. Which of the following nursing interventions should the nurse explore to support the client's current needs?
- A. Call the physician to discuss allowing the client to return to work earlier.
- B. Suggest that the client learn relaxation techniques for help with her insomnia.
- C. Perform a nutritional assessment to assess for anorexia.
- D. Ask open-ended questions about sexuality issues related to her mastectomy.
Correct Answer: B
Rationale: Insomnia is a primary concern, and relaxation techniques can help improve sleep, addressing the client's emotional and physical recovery needs post-mastectomy.
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?
- A. Change dressing per institutional policy.
- B. Culture drainage at insertion site.
- C. Notify physician.
- D. Position rolled towel under client's back, parallel to the spine.
Correct Answer: C,B,A,D
Rationale: The priority is to notify the physician (C) due to potential infection indicated by a moist dressing, followed by culturing drainage (B) to identify the organism, changing the dressing (A) to maintain sterility, and positioning a towel (D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which of the following indicates this client is ready to be discharged?
- A. The client voids 500 mL of urine.
- B. The client tolerates eating a hamburger.
- C. The client is pain-free.
- D. The client walks in the hallway unassisted.
Correct Answer: A
Rationale: Voiding 500 mL indicates normal bladder function, a key discharge criterion after hernia repair, ensuring no urinary retention from anesthesia or surgery.
A client who has been diagnosed with peripheral vascular disease (PVD) is being discharged. The client needs further instruction if she says she will:
- A. Avoid heating pads
- B. Not cross her legs
- C. Wear leather shoes
- D. Use iodine on an injured site
Correct Answer: D
Rationale: Using iodine on an injured site is incorrect, as it can be cytotoxic and impair wound healing in PVD, where tissue perfusion is already compromised. Avoiding heating pads (risk of burns), not crossing legs (improves circulation), and wearing leather shoes (protects feet) are appropriate self-care measures.