Nokea
After the nurse teaches a client about wearing a back brace after a spinal fusion, which of the following client statements indicates effective teaching?
- A. I will apply lotion before putting on the brace.'
- B. I will be sure to pad the area around my iliac crest.'
- C. I will use baby powder under the brace to absorb perspiration.'
- D. I will wear a thin cotton undershirt under the brace.'
Correct Answer: D
Rationale: A thin cotton undershirt prevents skin irritation while allowing the brace to fit properly.
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When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply.
- A. The drug can be used if the person is allergic to aspirin.
- B. Acetaminophen does not affect platelet aggregation.
- C. This drug causes little or no gastric distress.
- D. Acetaminophen exerts a strong antiinflammatory effect.
- E. The client should have the International Normalized Ratio (INR) checked regularly.
Correct Answer: A,B,C
Rationale: Acetaminophen is safe for aspirin allergies, does not affect platelets, and causes minimal gastric distress. It has weak anti-inflammatory effects and does not require INR monitoring.
A client is newly diagnosed with cancer and is beginning a treatment plan. Which of the following nursing interventions will be most effective in helping the client cope?
- A. Assume decision making for the client.
- B. Encourage the client's compliance with all treatment regimens.
- C. Inform the client of all possible adverse treatment effects.
- D. Identify available resources.
Correct Answer: D
Rationale: Identifying available resources (e.g., support groups, counseling) empowers the client to cope with the emotional and practical challenges of a new cancer diagnosis.
A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse incorporate into the discharge instructions? Select all that apply.
- A. A limit of least 3,000 mL of fluid each day.
- B. Minimize daily activities.
- C. Keep urine alkaline to prevent urinary tract infections.
- D. Avoid odor-producing foods, such as onions, fish, eggs, and cheese.
- E. Wear snug clothing over the stoma to encourage urine flow into the drainage bag.
Correct Answer: A,D
Rationale: An adequate fluid intake aids in the prevention of urinary calculi and infection. Odor-producing foods should be avoided as they can affect the client's lifestyle and relationships. Minimizing activities can lead to urinary stasis, promoting infection. Alkaline urine may increase infection risk, and snug clothing is not recommended as it may irritate the stoma.
Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg?
- A. Give the client a warming blanket.
- B. Administer low-dose barbiturates.
- C. Encourage the client to hyperventilate.
- D. Restrict fluids.
Correct Answer: B
Rationale: Low-dose barbiturates can reduce cerebral metabolism and ICP, making them appropriate in some cases under medical supervision. Warming blankets increase metabolic demand, hyperventilation is no longer routinely recommended due to risks of cerebral vasoconstriction, and fluid restriction is not standard for ICP management unless specifically indicated.
Glulisine (Apidra) insulin is ordered to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client 'went for a test.' What should the nurse do next?
- A. Bring a small glass of juice, and locate the client.
- B. Call the client's physician.
- C. Check the computerized care plan to determine the test.
- D. Send the nurse's assistant to the X-ray department to bring the client back to his room.
Correct Answer: A
Rationale: Glulisine is rapid-acting insulin, and the client must eat within 15 minutes to prevent hypoglycemia. The nurse should locate the client and provide juice to counteract potential hypoglycemia.