Nokea
An adult had an open cholecystectomy and has an open wound. The client refuses to look at the area during the dressing change. What is the most likely reason for this behavior?
- A. Denial of surgery
- B. Change in body image
- C. The client fears becoming nauseated at the sight of the wound.
- D. The client does not like the sight of blood.
Correct Answer: B
Rationale: Refusing to look at the wound suggests difficulty accepting a change in body image post-cholecystectomy, a common emotional response.
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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.
A nurse is caring for a patient with diabetes mellitus who is scheduled for surgery. Which of the following is the most important preoperative assessment?
- A. Blood glucose level.
- B. Electrolyte levels.
- C. Complete blood count (CBC).
- D. Urinalysis.
Correct Answer: A
Rationale: Blood glucose control is critical preoperatively in diabetes to prevent complications like wound infections or ketoacidosis. Electrolytes, CBC, and urinalysis are important but secondary, as glucose directly impacts surgical outcomes.
A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?
- A. A private room down the hall from the nurses' station
- B. An isolation room close to the nurses' station
- C. A semiprivate room with a 32-year-old client who has viral meningitis
- D. A two-bed room with a client who previously had bacterial meningitis
Correct Answer: B
Rationale: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.
When a patient return from the recovery room following a subtotal thyroidectomy, the nurse should immediately
inspect the incision.
- A. instruct the patient not to speak.
- B. keep the patient supine for 24 hours.
- C. place a tracheostomy set at the bedside.
Correct Answer: D
Rationale: Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema also causes obstruction. Having a tracheostomy set ready is critical.
Which of the following is the primary force in sex education in a child's life?
- A. school nurse
- B. peers
- C. parents
- D. media
Correct Answer: C
Rationale: Parents are the primary influence on a child's sex education, providing foundational values and information. Other sources like peers and media are influential but secondary. Health Promotion and Maintenance