Nokea
A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states:
- A. I will make sure my medications are enteric-coated
- B. My stoma will drain liquid continuously
- C. I will change my pouch system every two weeks
- D. My stoma size will stay the same after it heals
Correct Answer: B
Rationale: The correct answer is B. When a client with an ileostomy states that their stoma will drain liquid continuously, it indicates an understanding of the expected outcome. In an ileostomy, the stoma continuously drains liquid stool as it bypasses the large intestine where water is absorbed. Choices A, C, and D are incorrect because ensuring medications are enteric-coated, changing the pouch system every two weeks, and expecting the stoma size to remain the same after healing are not accurate statements related to an ileostomy.
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A nurse is caring for a client who has congestive heart failure. Which of the following prescriptions from the provider should the nurse anticipate?
- A. Call the provider if the client's respiratory rate is less than 18/min
- B. Administer 500 mL IV bolus of 0.9% sodium chloride over 1 hour
- C. Administer enalapril 2.5 mg PO twice daily
- D. Call the provider if the client's pulse rate is less than 80/min
Correct Answer: C
Rationale: The correct answer is C. Enalapril is an ACE inhibitor commonly prescribed for clients with congestive heart failure to help reduce blood pressure and fluid overload. Option A is incorrect as in congestive heart failure, a lower respiratory rate could be a sign of worsening condition and needs immediate attention rather than waiting to call the provider. Option B is incorrect as administering a large IV bolus of sodium chloride could exacerbate fluid overload in a client with heart failure. Option D is incorrect as a pulse rate lower than 80/min may not necessarily indicate a problem in a client with congestive heart failure.
A client wearing an arm cast reports numb fingers. Which of the following actions should the nurse take first?
- A. Place the arm in a dependent position
- B. Administer pain medication
- C. Check the client's circulation
- D. Apply a warm compress to the fingers
Correct Answer: C
Rationale: The correct answer is to check the client's circulation. Numbness in the fingers may indicate compromised circulation or nerve damage. By assessing the circulation first, the nurse can ensure that the cast is not too tight, which could be cutting off blood flow. Option A is incorrect because placing the arm in a dependent position may worsen circulation issues. Option B is incorrect as administering pain medication does not address the underlying cause of numbness. Option D is incorrect as applying a warm compress could mask circulation issues and is not the priority in this situation.
A nurse is assessing a client who was brought to the psychiatric emergency services by law enforcement. The client has disorganized, incoherent speech with loose associations and religious content. The nurse should recognize these signs and symptoms as consistent with which of the following?
- A. Alzheimer's disease
- B. Schizophrenia
- C. Substance intoxication
- D. Depression
Correct Answer: B
Rationale: The correct answer is B: Schizophrenia. Disorganized speech, loose associations, and religious delusions are characteristic symptoms of schizophrenia. In this scenario, the client's presentation aligns with positive symptoms of schizophrenia, indicating a severe mental disorder requiring immediate attention. Choice A, Alzheimer's disease, primarily involves cognitive decline and memory impairment, not disorganized speech or religious content. Choice C, Substance intoxication, may present with altered mental status but typically lacks the persistent pattern of symptoms seen in schizophrenia. Choice D, Depression, is associated with a different set of symptoms such as low mood, anhedonia, and changes in appetite or sleep, rather than disorganized speech and loose associations.
A nurse is developing discharge care plans for a client who has osteoporosis. To prevent injury, the nurse should instruct the client to:
- A. Perform weight-bearing exercises
- B. Avoid crossing the legs beyond the midline
- C. Avoid sitting in one position for prolonged periods
- D. Splint the affected area
Correct Answer: A
Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises strengthen bones and help prevent fractures, which is crucial for clients with osteoporosis. Choices B, C, and D are incorrect. Avoiding crossing the legs beyond the midline and avoiding sitting in one position for prolonged periods are general recommendations for preventing musculoskeletal issues but are not specific to osteoporosis. Splinting the affected area is not a standard practice for managing osteoporosis and preventing fractures.
A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
- A. WBC 3,000/mm3
- B. Hemoglobin 14 g/dL
- C. Platelets 250,000/mm3
- D. aPTT 30 seconds
Correct Answer: A
Rationale: A WBC count of 3,000/mm3 indicates neutropenia, a dangerous complication of chemotherapy that increases the risk of infection and requires immediate attention. Neutropenia is a common side effect of chemotherapy and can lead to life-threatening infections. Reporting a low WBC count is crucial to ensure timely intervention. Choices B, C, and D are within normal ranges and do not pose immediate risks to the client undergoing chemotherapy.