Nokea
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
- A. This is a routine surgery and the risk of death is very low.
- B. Would you like to speak with a chaplain before surgery?
- C. Tell me more about your concerns about the surgery.
- D. What support systems do you have to assist you?
Correct Answer: C
Rationale: Encouraging the client to express their concerns allows the nurse to provide emotional support and address specific fears.
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Which statement by the mother of a child with rheumatic fever (RF) shows she has a good understanding of the care of her child?
- A. I will apply heat to his swollen joints to promote circulation.
- B. I will have him do gentle stretching exercises to prevent contractures.
- C. I will give him the aspirin that is ordered for pain and inflammation.
- D. I will apply cold packs to his swollen joints to reduce pain.
Correct Answer: C
Rationale: Aspirin is the drug of choice for treating RF due to its anti-inflammatory and analgesic properties.
A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?
- A. What time did he take his last medications?
- B. Has his weight changed in the last several days?
- C. Is he still able to tighten his belt buckle?
- D. How many hours did he sleep last night?
Correct Answer: B
Rationale: Weight gain is a key indicator of fluid retention in heart failure, which can exacerbate symptoms.
The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is required, round to the nearest tenth.)
- A. 0.9
- B. 1
- C. 9
Correct Answer: A
Rationale: The calculation is based on the prescribed dose and the concentration of the medication.
José is a 4-year-old child scheduled for a cardiac catheterization. What should be included in preoperative teaching?
- A. Directed at his parents because he is too young to understand
- B. Detailed in regard to the actual procedures so he will know what to expect
- C. Done several days before the procedure so that he will be prepared
- D. Adapted to his level of development so that he can understand
Correct Answer: D
Rationale: Preoperative teaching should always be directed at the child’s stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. Preschoolers will not understand in-depth descriptions and should be prepared close to the time of the cardiac catheterization.
Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?
- A. Avoid coiling the tubing and keep if free of kinks
- B. Cleanse the perineal area with soap and water twice daily
- C. Keep the drainage bag lower than the level of the bladder
- D. Drink 1,000 ml of fluids daily to irrigate catheter
Correct Answer: C
Rationale: Keeping the drainage bag lower than the bladder prevents backflow of urine, reducing the risk of infection.