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A nurse is providing discharge teaching to a client who is postoperative following a mastectomy. Which of the following instructions should the nurse include?
- A. Avoid using deodorant until the incision heals.
- B. Perform arm exercises 24 hours after surgery.
- C. Wear tight-fitting clothing to support the incision.
- D. Perform arm exercises 2 days after surgery.
Correct Answer: A
Rationale: The correct instruction for the nurse to include is to advise the client to avoid using deodorant until the incision heals. Using deodorant can lead to skin irritation, which should be prevented following a mastectomy. Choice B is incorrect because performing arm exercises should typically be delayed until recommended by the healthcare provider to prevent strain on the surgical site. Choice C is incorrect as tight-fitting clothing can increase discomfort and hinder proper healing. Choice D is also incorrect because initiating arm exercises should be based on the healthcare provider's guidance and not a specific timeframe.
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A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
- A. Auscultate the apical pulse and count for 1 minute
- B. Place a sensor on the index finger
- C. Heat the skin prior to placing the probe
- D. Recheck after 10 minutes
Correct Answer: A
Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.
How should a healthcare professional monitor for infection in a patient with a central line?
- A. Check the central line dressing daily
- B. Monitor for signs of redness
- C. Check for abnormal breath sounds
- D. Monitor temperature
Correct Answer: A
Rationale: Correct answer: A. Checking the central line dressing daily is crucial to monitor for signs of infection around the insertion site. This practice helps in early detection of any changes such as redness, swelling, or discharge, which are indicators of a potential infection. Monitoring for signs of redness (choice B) is limited as redness alone may not always indicate an infection; other symptoms like discharge and tenderness should also be observed. Checking for abnormal breath sounds (choice C) is not directly related to monitoring central line infections. Monitoring temperature (choice D) is important for detecting systemic signs of infection but may not specifically indicate an infection related to the central line site.
A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?
- A. Encourage the client to take deep breaths.
- B. Administer oxygen as needed.
- C. Teach the client pursed-lip breathing.
- D. Limit the client's fluid intake.
Correct Answer: C
Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.
Which electrolyte imbalance should be closely monitored in patients on diuretics?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Patients on diuretics are at risk of developing hypokalemia due to increased potassium excretion by the kidneys. Hypokalemia can lead to serious consequences such as cardiac arrhythmias. Hyponatremia (choice B) is an imbalance of sodium levels and is not typically associated with diuretic use. Hyperkalemia (choice C) is the opposite condition where potassium levels are elevated and is less common in patients on diuretics. Hypercalcemia (choice D) is an excess of calcium in the blood and is not directly related to diuretic use. Therefore, monitoring for hypokalemia is crucial in patients taking diuretics.
Which medication is used to manage hyperthyroidism?
- A. Levothyroxine
- B. Methimazole
- C. Propylthiouracil
- D. Prednisone
Correct Answer: B
Rationale: Methimazole is the correct answer. It is commonly used to manage hyperthyroidism by inhibiting the production of thyroid hormones. Levothyroxine (Choice A) is actually a medication used to treat hypothyroidism by supplementing thyroid hormones. Propylthiouracil (Choice C) is another anti-thyroid medication used in the management of hyperthyroidism. Prednisone (Choice D) is a corticosteroid and is not typically used in the treatment of hyperthyroidism.