Nokea
A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure (LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect heavy bleeding for the next week.
- B. I will avoid using tampons for the next few weeks.
- C. I should resume sexual activity within 24 hours.
- D. I will avoid all physical activity for a month.
Correct Answer: B
Rationale: The correct answer is B: "I will avoid using tampons for the next few weeks." This statement indicates an understanding of the discharge teaching because using tampons can introduce bacteria into the healing cervix, increasing the risk of infection post-LEEP. Choosing this answer demonstrates knowledge of the importance of maintaining good hygiene and minimizing infection risk during the healing process.
Other choices are incorrect:
A: Expecting heavy bleeding for the next week is incorrect as heavy bleeding should decrease gradually.
C: Resuming sexual activity within 24 hours is incorrect as it can increase the risk of infection and disrupt the healing process.
D: Avoiding all physical activity for a month is incorrect as light activities are usually allowed, and complete inactivity can lead to complications like blood clots.
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A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through the air via droplet nuclei. Implementing airborne precautions involves placing the client in a negative pressure room, using an N95 respirator, and ensuring proper ventilation. Standard precautions (A) are used for all clients. Contact precautions (C) are used for clients with infections that can be spread by direct or indirect contact. Droplet precautions (D) are used for infections spread through larger respiratory droplets. In this case, airborne precautions are specifically needed due to the mode of transmission of tuberculosis.
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?
- A. I feel overwhelmed and unsure if I can handle this responsibility.
- B. I changed the floor plan of our home to accommodate my fathers wheelchair.
- C. I wish my siblings would help more with our parents care.
- D. I often feel resentful about the extra responsibilities.
Correct Answer: B
Rationale: The correct answer is B. Changing the floor plan of the home to accommodate the father's wheelchair demonstrates acceptance of the caregiving role. This action shows that the client is willing to make necessary adjustments for their parents' needs, indicating a commitment to the role change.
A: Feeling overwhelmed and unsure indicates resistance to the role change.
C: Wishing for siblings' help suggests a desire to share responsibilities, not necessarily acceptance.
D: Feeling resentful points towards negative emotions, which do not align with acceptance.
A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?
- A. 0.4 mL
- B. 0.5 mL
- C. 0.6 mL
- D. 0.7 mL
Correct Answer: B
Rationale: To calculate the dose of enoxaparin, first convert the client's weight from pounds to kilograms: 154 lb/2.2 = 70 kg. Then, calculate the dose: 0.75 mg/kg x 70 kg = 52.5 mg. Since the concentration is 60 mg/0.6 mL, divide the dose needed by the concentration: 52.5 mg/60 mg x 0.6 mL = 0.5 mL. Therefore, the correct answer is B (0.5 mL). Choice A is incorrect as it is less than the calculated dose. Choice C is incorrect as it is based on the concentration but does not match the calculated dose. Choice D is incorrect as it is higher than the calculated dose.
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
- A. Report cloudy dialysate drainage to the provider.
- B. Lower the drainage bag below the level of the abdomen.
- C. Encourage fluid intake of 3L per day.
- D. Use sterile gloves only when removing the catheter.
Correct Answer: A
Rationale: The correct answer is A: Report cloudy dialysate drainage to the provider. Cloudy dialysate drainage can indicate infection, leading to peritonitis. The nurse should report this immediately for further evaluation and treatment to prevent complications. Lowering the drainage bag below the abdomen (B) can cause backflow, increasing the risk of contamination. Encouraging fluid intake of 3L per day (C) is a general recommendation but not specific to peritoneal dialysis. Using sterile gloves only when removing the catheter (D) is incorrect as sterile technique is required during all catheter manipulations in peritoneal dialysis.
A nurse is caring for a client who has acute kidney injury and a potassium level of 6.5 mEq/L. Which of the following ECG changes should the nurse expect?
- A. Flattened T waves
- B. Peaked T waves
- C. Prolonged PR interval
- D. ST segment depression
Correct Answer: B
Rationale: The correct answer is B: Peaked T waves. In hyperkalemia (high potassium level), the myocardium becomes more excitable, leading to changes in the ECG. Peaked T waves are a classic sign of hyperkalemia, indicating early stages of cardiac involvement. Flattened T waves (choice A) are associated with hypokalemia. Prolonged PR interval (choice C) and ST segment depression (choice D) are not typically seen in hyperkalemia.