Nokea
A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?
- A. Take the sample from the outer edge of formed stool.
- B. Wear sterile gloves when collecting the sample.
- C. Collect three samples from a single bowel movement.
- D. Discard samples that contain urine.
Correct Answer: D
Rationale: The correct answer is D: Discard samples that contain urine. This is crucial because urine can interfere with the accuracy of the fecal occult blood test results, leading to false positives. By discarding samples that contain urine, the nurse ensures the reliability of the test.
A: Taking the sample from the outer edge of formed stool is not necessary for a guaiac smear sample.
B: Wearing sterile gloves is important for infection control but not specifically for collecting a guaiac smear sample.
C: Collecting three samples from a single bowel movement is not standard practice for fecal occult blood testing and may not be necessary.
E, F, G: No further options provided.
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A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform strength-building arm exercises using a 15-pound weight.'
- B. I should expect less than 25 mL of secretions per day in the drainage devices.'
- C. I will have to wait 2 months before additional saline can be added to my breast expander.'
- D. I will keep my left arm flexed at the elbow as much as possible.'
Correct Answer: B
Rationale: The correct answer is B: "I should expect less than 25 mL of secretions per day in the drainage devices." This demonstrates an understanding of the need to monitor drainage postoperatively. Excessive drainage can indicate complications like infection or bleeding.
A: Performing strength-building exercises with a 15-pound weight is contraindicated postoperatively as it can strain the surgical site.
C: Waiting 2 months before adding saline to the expander is incorrect. Saline can be added gradually postoperatively.
D: Keeping the left arm flexed at the elbow is not recommended as it can lead to stiffness and limited range of motion.
A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?
- A. Your breathing pattern causes this.'
- B. This means your lung is fully re-expande '
- C. Suction pressure that is too high causes this.'
- D. This indicates a possible air leak.'
Correct Answer: A
Rationale: The correct answer is A: "Your breathing pattern causes this." The fluctuation in the fluid level of the water-seal chamber of a chest tube system is directly related to changes in intrathoracic pressure during breathing. As the client breathes in and out, the negative pressure in the pleural space increases and decreases, causing the fluid to rise and fall in the water-seal chamber. This movement is a normal physiological response and indicates proper functioning of the chest tube system. Choices B, C, and D are incorrect because they do not accurately explain the reason for the fluid fluctuation in the water-seal chamber. Choice B is incorrect as lung re-expansion does not directly cause the fluid movement. Choice C is incorrect as high suction pressure does not cause this specific phenomenon. Choice D is incorrect as fluid movement does not indicate an air leak.
A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
- A. Instruct the client to use their elbows to reposition.
- B. Remove the weights before changing the client's bedlinens.
- C. Check pressure points every 12 hr.
- D. Provide the client with a trapeze bar.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a trapeze bar. This is essential for the client in skeletal traction to independently move and reposition themselves safely without putting additional stress on the affected leg. Using elbows (A) can disrupt the traction. Removing weights (B) can lead to complications. Checking pressure points (C) is important but not specific to this situation. The trapeze bar (D) promotes client independence and safety.
A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?
- A. Brush your teeth for 60 seconds twice daily.
- B. Wear your dentures only during meals.
- C. Floss your teeth gently following each meal.
- D. Rinse your mouth with hydrogen peroxide.
Correct Answer: B
Rationale: The correct answer is B: Wear your dentures only during meals. This instruction is important for a client with mucositis because wearing dentures continuously can exacerbate irritation and discomfort in the mouth. By removing dentures between meals, the client can allow the oral tissues to rest and promote healing.
Choice A is incorrect because vigorous brushing for 60 seconds can further irritate the mucositis. Choice C is incorrect as flossing can also cause trauma to the inflamed tissues. Choice D is incorrect as rinsing with hydrogen peroxide can be too harsh and may worsen the condition. It's important to provide gentle care and minimize irritation to the affected areas in mucositis.
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for dietary consult. The client tells the nurse, 'I will have to eat whatever the dietitian tells me.' Which of the following statements by the nurse encourages the client's involvement in their plan of care?
- A. The dietitian will provide you with the best food choices to manage your diabetes.'
- B. I understand that the dietary choices can seem overwhelming.'
- C. I can assist you with making a list of foods you like for the dietitian.'
- D. Managing your diabetes will require you to make accommodations.'
Correct Answer: C
Rationale: The correct answer is C because it encourages the client's involvement in their plan of care by actively engaging them in the decision-making process. By offering to assist the client in making a list of foods they like for the dietitian, the nurse is promoting client autonomy and empowerment. This approach helps the client feel more in control of their dietary choices and encourages collaboration between the client, nurse, and dietitian.
Choice A is incorrect as it does not actively involve the client in decision-making. Choice B acknowledges the client's feelings but does not directly engage them in the process. Choice D focuses on the client's responsibilities but does not promote active participation.