Nokea
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 will no longer need regular gynecological examinations.
- B. I will have a large scar on my stomach after this procedure.
- C. I am thankful I am done having children.
- D. I should expect my periods to resume in 1 month.
Correct Answer: C
Rationale: Expressing relief about no more children suggests understanding of the procedure's outcome.
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The client was prescribed azithromycin 1 g PO once.
A nurse in a health clinic is assisting in the care of a client diagnosed with chlamydia. The client was prescribed azithromycin 1 g PO once. Which of the following allergy findings in the client's history should the nurse report to the provider?
- A. Allergy to tetracyclines
- B. Allergy to sulfonamides
- C. Allergy to macrolides
- D. Allergy to penicillins
Correct Answer: C
Rationale: Azithromycin is a macrolide; an allergy to macrolides contraindicates its use.
The client delivered a newborn by cesarean birth 1 day ago.
A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?
- A. You can apply counterpressure to your back with each position change.
- B. You should change positions as little as possible.
- C. You can splint the incision with a pillow when changing positions.
- D. You should use patterned-paced breathing when changing positions.
Correct Answer: C
Rationale: Splinting the incision with a pillow reduces pain during movement.
The client has quadriplegia.
A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?
- A. Place the client's glasses on the bedside table.
- B. Place the call light within the client's reach.
- C. Check on the client every 4 hr.
- D. Place the client in a room near the nurses' station.
Correct Answer: B
Rationale: Placing the call light within reach ensures the client can summon help.
The client reports feeling stress.
A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?
- A. Recurring urinary tract infections
- B. A recent move to a new city
- C. Report of feeling depressed
- D. Lack of nutritional knowledge
Correct Answer: B
Rationale: A recent move is an external stressor, unlike internal health or knowledge factors.
A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?
- A. Educate the infant's guardians about exchange transfusion.
- B. Administer granulocyte colony-stimulating factor.
- C. Initiate droplet precautions.
- D. Monitor the infant's lymphocyte count.
Correct Answer: D
Rationale: Monitoring lymphocyte count tracks HIV progression in infants.