Nokea
An adolescent is being prepared for an emergency appendectomy. The nurse should tell the client? Select all that apply.
- A. Friends can visit whenever they want.
- B. The scar will be small.
- C. The teen will be back in school in 1 week.
- D. Antibiotics will be given to prevent an infection.
- E. A dressing will stay in place for 1 week.
Correct Answer: B,C,D
Rationale: A small scar, school return in about a week, and prophylactic antibiotics are accurate expectations for appendectomy recovery. Unrestricted visits and prolonged dressing use are incorrect.
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A client with a history of hypertension is prescribed hydrochlorothiazide (HCTZ). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypermagnesemia.
- D. Hypercalcemia.
Correct Answer: A
Rationale: Hydrochlorothiazide, a thiazide diuretic, can cause hypokalemia due to potassium loss.
The home health nurse cares for an obese adult client. In the client's medical record, the nurse reads, 'The client has a sprained right ankle, has not exercised for more than 1 week, and has missed the last two physical therapy appointments.' The client says, 'I attend therapy for my ankle and I do my exercises three times a day.' Which response should the nurse use with the client?
- A. Show me the exercises that you perform in physical therapy.
- B. You will never heal if you skip the physical therapy sessions.
- C. Your progress sounds fine. Is more physical therapy scheduled?
- D. I see that you missed the last two physical therapy appointments.
Correct Answer: D
Rationale: In the correct option, the nurse employs the therapeutic communication technique of confrontation. Because the client is employing avoidance, the nurse presents the facts according to the medical record to assess the client's perspective without accusing, threatening, or humiliating the client about the missed physical therapy. By confronting, the nurse assists the client with problem-solving. Option 1 is potentially helpful when the client is complying with therapy. In option 2, the nurse provides an opinion and this statement admonishes the client for the behavior. In option 3, the nurse is nontherapeutic in giving approval and is mirroring the client's avoidance and passivity by not dealing directly with the problem of missed appointments.
When teaching unlicensed assistive personnel (UAP) about the importance of hand washing in preventing disease, the nurse should instruct the UAP that?
- A. It is not necessary to wash your hands as long as you use gloves.'
- B. Handwashing is the best method for preventing cross-contamination.'
- C. Waterless commercial products are not effective for killing organisms.'
- D. The hands do not serve as a source of infection.'
Correct Answer: B
Rationale: Handwashing is the most effective method to prevent cross-contamination, as hands are a primary source of infection transmission in healthcare settings.
Which of the following correctly describes Medicaid?
- A. A program designed to assist ill, low-income older adults.
- B. A federal insurance program for pregnant women.
- C. A joint federal-state program for low-income persons.
- D. A program administered by health maintenance organizations.
Correct Answer: C
Rationale: Medicaid is a joint federal-state program providing healthcare coverage for low-income individuals, including children, pregnant women, and the elderly.
A client with a history of myocardial infarction is prescribed aspirin. The nurse should explain that the primary purpose of this medication is to:
- A. Reduce chest pain.
- B. Prevent platelet aggregation.
- C. Lower blood pressure.
- D. Decrease heart rate.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of further clot formation in clients with a history of myocardial infarction.