Nokea
48
A nurse is reinforcing bladder management instructions with a client who has urinary incontinence. Which of the following statements by the client indicates an understanding?
- A. I should use the bathroom at set times during the day.
- B. I can continue to drink coffee every day.
- C. I can insert a catheter in my bladder at bedtime.
- D. I should stop drinking fluids an hour before bedtime.
- E. I'll avoid pelvic floor exercises.
- F. I can drink alcohol freely.
- G. I should ignore urges to urinate.
Correct Answer: A
Rationale: Scheduled voiding helps manage incontinence; coffee and alcohol worsen it, and self-catheterization isn't routine.
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A nurse is evaluating a client's acceptance of having a new ileostomy. Which of the following statements by the client indicates acceptance?
- A. I wish my sexual relationship with my partner was like it was before.
- B. I have my partner empty the bag for me, so I don't have to look at it
- C. I look forward to having normal bowel movements again.
- D. I will attend a support group to help me handle difficulties when they occur.
Correct Answer: D
Rationale: Attending a support group shows proactive acceptance and coping with the ileostomy. Other statements reflect denial or avoidance of the new reality.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?
- A. Abdominal wound dry, without redness
- B. Client received an adequate amount of fluid
- C. Client status unchanged throughout shift
- D. Incision healing well
- E. Pain level stable
- F. No fever noted
- G. Ambulated without difficulty
Correct Answer: A
Rationale: Specific, objective data like 'dry, without redness' is required; vague terms like 'adequate' or 'unchanged' are insufficient.
A nurse is assisting with the care of a client who has a seizure disorder. Which of the following supplies should the nurse have at the client's bedside at all times?
- A. Suction equipment
- B. Padded tongue blades
- C. Backboard
- D. Wrist restraints
Correct Answer: A
Rationale: Suction equipment clears airways during a seizure, preventing aspiration. Tongue blades are outdated, and restraints or backboards are not standard bedside items for seizure care.
A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Peripheral edema
- C. Decreased respirations
- D. Absent bowel sounds
Correct Answer: D
Rationale: Absent bowel sounds indicate paralytic ileus, a common finding in peritonitis due to inflammation. Polyuria, edema, and decreased respirations are not typical.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Replace the unit when the drainage chamber is full.
- B. Monitor for at least 150 mL of drainage every hour.
- C. Clamp the tube for 30 min every 8 hr.
- D. Pin the tubing to the client's bed sheets.
Correct Answer: A
Rationale: Chest tube systems remove pleural air or fluid, requiring functionality. Replacing the unit when full prevents backpressure or overflow, maintaining drainage and lung re-expansion, per manufacturer and infection control standards (e.g., CDC). Monitoring 150 mL/hr is excessive sudden high output signals hemorrhage, not routine care. Clamping risks tension pneumothorax by trapping air/fluid, only done briefly for specific checks (e.g., air leak). Pinning tubing prevents dislodgement, but full chamber replacement is the proactive maintenance action. This ensures system efficacy, prevents complications like atelectasis, and aligns with respiratory care priorities, making it the nurse's key responsibility.