Nokea
A postoperative client is to be discharged today. She will need to change her dressing daily. Which statement she makes indicates that she understands the process?
- A. I will wash my hands before and after I change the dressing.'
- B. I can touch the dressings with my hands if I only touch the edges.'
- C. I should clean the area around the incision by moving the swab toward it.'
- D. I can put the old dressings directly in the waste basket.'
Correct Answer: A
Rationale: Hand washing before and after dressing changes prevents infection, reflecting proper understanding. Touching dressings, cleaning toward the incision, or improper disposal increase infection risk.
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After a painful exacerbation of rheumatoid arthritis, a patient is to begin a walking and exercise program.
An appropriate outcome would be that the patient:
- A. Avoids exercising when there is some discomfort.
- B. Is pain free while engaging in the activity program.
- C. Walks and exercise even when the pain is severe.
- D. Exercise unless the discomfort becomes too great.
Correct Answer: D
Rationale: Exercising until discomfort becomes too great balances activity with joint protection, promoting safe participation.
A client who had a total thyroidectomy this morning is to be admitted to the surgical floor. What should the nurse have readily available when the client arrives?
- A. Tracheostomy set
- B. Catheterization tray
- C. Sterile dressing set
- D. Ventilator
Correct Answer: A
Rationale: Thyroidectomy risks airway obstruction from swelling or hematoma; a tracheostomy set is essential for emergency airway management.
You're filling in as a substitute school nurse. When an 11-year-old child with an earache and sore throat reports to the nurse's office, you inspect the tympanic membrane using an otoscope.
Which color suggests a normal eardrum?
- A. Red
- B. White
- C. Gray
- D. Yellowish
Correct Answer: C
Rationale: A normal eardrum appears pearly gray.
The nurse is caring for a newborn who has just been diagnosed with hypospadias. When discussing the defect with the parents, the nurse should communicate that
- A. Circumcision can be performed at any time
- B. Initial repair is delayed until 6-8 years of age
- C. Post-operative appearance will be normal
- D. Surgery will be performed in stages
Correct Answer: D
Rationale: Surgery will be performed in stages. Hypospadias correction is done in stages as soon as the infant can tolerate surgery.
The patient with hypothyroidism
The patient with hypothyroidism will most likely experience which of the following?
- A. Diarrhea and weight gain.
- B. Warm skin and brittle nails.
- C. Dry skin and weight gain.
- D. Constipation and tachycardia.
Correct Answer: C
Rationale: Hypothyroidism causes dry skin and weight gain due to slowed metabolism.