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A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?
- A. I should expect my periods to resume in 1 month.
- B. I will no longer need a regular gynecological examination.
- C. I am thankful I am done having children.
- D. I will have a large scar on my stomach after this procedure.
Correct Answer: C
Rationale: The statement about being done having children shows the client understands the procedure's impact on fertility, a key component of informed consent. The other statements reflect misunderstandings about the procedure's outcomes.
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A nurse is caring for a client who is receiving IV fluids with potassium chloride. Which of the following findings should the nurse report to the provider?
- A. The client reports mild discomfort at the IV site.
- B. The client's heart rate is irregular.
- C. The client's urine output is 50 mL/hr.
- D. The client's blood pressure is 118/76 mm Hg.
Correct Answer: B
Rationale: An irregular heart rate suggests hyperkalemia or arrhythmia, requiring reporting. Mild discomfort, normal urine output, and stable BP are less concerning.
A nurse is caring for a client who is receiving continuous bladder irrigation following a TURP. Which of the following findings should the nurse report to the provider?
- A. The client reports bladder spasms.
- B. The irrigation fluid is slightly pink.
- C. The client's urine output is bright red with clots.
- D. The client's catheter is draining freely.
Correct Answer: C
Rationale: Bright red urine with clots indicates potential hemorrhage, requiring immediate reporting. Spasms and pink fluid are expected, and free drainage is normal.
A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports shoulder pain.
- B. The client's temperature is 38.2°C (100.8°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with slight redness.
Correct Answer: B
Rationale: A temperature of 38.2°C suggests infection, requiring reporting. Shoulder pain is referred pain, no bowel movement is expected, and slight redness is normal.
A nurse is reinforcing discharge teaching with a client who has a prescription for antibiotic therapy. The client reports experiencing diarrhea when taking antibiotics. Which of the following foods should the nurse recommend to lessen the occurrence of diarrhea?
- A. Coffee
- B. Ice cream
- C. Apple juice
- D. Yogurt
Correct Answer: D
Rationale: Yogurt's probiotics help restore gut flora, reducing antibiotic-associated diarrhea. Coffee, ice cream, and apple juice may worsen diarrhea due to their diuretic, lactose, or sugar content.
A nurse is caring for a client who is receiving IV chemotherapy. Which of the following findings should the nurse report to the provider?
- A. The client reports mild fatigue.
- B. The client's IV site is cool and swollen.
- C. The client's urine output is 200 mL over 4 hr.
- D. The client's temperature is 37.2°C (99°F).
Correct Answer: B
Rationale: A cool, swollen IV site suggests extravasation, a chemotherapy emergency requiring immediate reporting. Fatigue, urine output, and mild fever are less urgent.