Nokea
A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should leave my steri-strips on until they fall off.
- B. I should expect to have nausea for several days.
- C. I should eat a high-fat diet for several weeks.
- D. I should expect to have diarrhea until my diet changes.
Correct Answer: A
Rationale: Leaving steri-strips on until they fall off promotes proper healing.
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A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?
- A. Puffed rice cereal
- B. Tomato juice
- C. Bran muffin
- D. Cottage cheese
- E. None
- F. None
Correct Answer: C
Rationale: Bran muffins are high in fiber, which promotes bowel regularity and indicates understanding.
A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for this client?
- A. NG tube
- B. Suction machine
- C. Syringe containing lorazepam
- D. Tongue blade
Correct Answer: B
Rationale: A suction machine clears airways during a seizure, enhancing safety.
The client is in renal failure.
A nurse is collecting data from a client who is in renal failure. Which of the following findings should the nurse identify as a manifestation of hyperkalemia?
- A. Dry mucous membranes
- B. Hyperactive reflexes
- C. Trousseau's sign
- D. Irregular heart rate
Correct Answer: D
Rationale: Irregular heart rate is a hallmark of hyperkalemia due to its effect on cardiac conduction.
A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?
- A. Difficulty swallowing
- B. Constipation
- C. Urinary retention
- D. Clenched teeth
Correct Answer: D
Rationale: Clenched teeth indicate ongoing pain despite the epidural.
A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
- A. Diminished pulses on the affected extremity
- B. Ecchymosis on the inner left thigh
- C. Client report of muscle spasms of the left leg
- D. One fingerbreadth of space between the cast and the skin
Correct Answer: A
Rationale: Diminished pulses suggest vascular compromise, a priority concern.