Nokea
A priority in the first 24 hours after a bilateral adrenalectomy is:
- A. Beginning oral nutrition.
- B. Promoting self-care activities.
- C. Preventing adrenal crisis.
- D. Ambulating in the hallway.
Correct Answer: C
Rationale: Preventing adrenal crisis is critical post-adrenalectomy due to sudden loss of adrenal hormone production, requiring steroid replacement.
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A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?
- A. Stabilize the leg with Buck's traction.
- B. Apply an ice pack to the affected hip.
- C. Position the client toward the opposite side of the hip.
- D. Notify the orthopedic surgeon.
Correct Answer: D
Rationale: Notifying the surgeon is the priority, as dislocation requires urgent medical intervention.
A client with terminal cancer is transitioning to hospice care. The nurse should prioritize which of the following in the care plan?
- A. Aggressive pain management.
- B. Curative chemotherapy.
- C. Nutritional supplementation.
- D. Physical therapy.
Correct Answer: A
Rationale: Aggressive pain management is the priority in hospice care to ensure comfort and quality of life for a client with terminal cancer.
The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated:
- A. Dust particles.
- B. Droplet nuclei.
- C. Water.
- D. Eating utensils.
Correct Answer: B
Rationale: Tuberculosis is primarily spread through droplet nuclei produced when an infected person coughs or sneezes. Dust, water, and utensils are not significant transmission routes.
A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
Which statement by a client with a new ileal conduit indicates a need for further teaching?
- A. I will empty the pouch when it is one-third full.
- B. I can use vinegar to clean my appliance.
- C. I should drink 2,000 mL of fluid daily.
- D. I will wear tight clothing to hide the pouch.
Correct Answer: D
Rationale: Tight clothing can irritate the stoma and impair appliance function, indicating a misunderstanding of proper care.