Nokea
A nurse is providing postmortem care for a client who has died of cancer. The most appropriate action is to:
- A. Remove all medical equipment immediately.
- B. Leave the body uncovered for family viewing.
- C. Bathe the body and position it respectfully.
- D. Notify the family to collect belongings quickly.
Correct Answer: C
Rationale: Bathing and positioning the body respectfully prepares it for family viewing and honors the deceased, aligning with postmortem care standards.
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The nurse in the preoperative holding area keeps a client with gastric bleeding in a dimly lit environment with one family member present. What is the primary rationale for these nursing interventions?
- A. To stabilize fluid and electrolyte balance.
- B. To minimize oxygen consumption.
- C. To increase client and family comfort.
- D. To prevent infection.
Correct Answer: B
Rationale: A dimly lit environment and limited visitors reduce stimulation, minimizing oxygen consumption in a client with gastric bleeding, who may be hypoxic due to anemia. Comfort is secondary, and these measures do not directly stabilize fluids or prevent infection.
A 65-year-old male has hearing loss and a sensation of fullness in both ears. The nurse examines his ears with the understanding of the cause of hearing loss in older adults is related to:
- A. Accumulation of cerumen in the external canal.
- B. Accumulation of cerumen in the internal canal.
- C. External otitis.
- D. Exostosis.
Correct Answer: A
Rationale: Accumulation of cerumen in the external canal is a common cause of conductive hearing loss in older adults, leading to a sensation of fullness and reduced hearing.
What is the purpose of sodium polystyrene sulfonate in acute renal failure?
- A. Lower blood pressure.
- B. Reduce serum potassium.
- C. Increase urine output.
- D. Correct acidosis.
Correct Answer: B
Rationale: Sodium polystyrene sulfonate removes potassium from the body, treating hyperkalemia.
After a laminectomy, the client states, 'The physician said that I can do anything I want to.' Which of the following client-stated activities indicates the need for further teaching?
- A. Drying the dishes.
- B. Sitting outside on firm cushions.
- C. Making the bed walking from side to side.
- D. Sweeping the front porch.
Correct Answer: D
Rationale: Sweeping involves twisting and bending, which can strain the surgical site post-laminectomy.
A client with lymphoma reports severe abdominal pain and distension. The nurse suspects tumor lysis syndrome (TLS). Which laboratory result would confirm this diagnosis?
- A. Serum potassium of 6.2 mEq/L.
- B. Serum sodium of 140 mEq/L.
- C. Serum calcium of 9.0 mg/dL.
- D. Serum glucose of 110 mg/dL.
Correct Answer: A
Rationale: TLS causes rapid cell breakdown, releasing potassium, leading to hyperkalemia (potassium >5.5 mEq/L), which confirms the diagnosis and requires urgent management.