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An awake postoperative client received an intravenous regional nerve block (Bier block) in the arm that is now casted and elevated on a pillow. What action should the nurse encourage the client to avoid until sensation returns?
- A. Holding the operated arm close to the face.
- B. Holding the operated arm with the unoperated arm.
- C. Using the unoperated arm.
- D. Using pain medication.
Correct Answer: A
Rationale: Without sensation, holding the arm close to the face risks injury, as the client may not feel pressure or positioning issues. The other actions are safe or unrelated.
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What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis?
- A. Don't worry. It's normal to feel that way.'
- B. Your friends are probably afraid of contracting hepatitis from you.'
- C. I'm sure you're imagining that!'
- D. Tell me more about your feelings of isolation.'
Correct Answer: D
Rationale: Encouraging the client to express feelings (D) promotes therapeutic communication and understanding. Dismissing feelings (A, C) or assuming others' fears (B) is non-therapeutic.
The nurse is caring for a client who sustained injuries from a light bulb explosion. On assessment, the nurse notes that a piece of glass was lodged in the client's eye. The initial nursing intervention should be which of the following?
- A. Attempt to carefully remove the glass from the eye
- B. Reassure the client that everything is okay
- C. Administer a sedative for pain relief
- D. Advise the client to remain in a sitting position until a specialist arrives
Correct Answer: D
Rationale: A foreign object like glass in the eye requires specialist intervention. Keeping the client in a sitting position minimizes further damage until a specialist evaluates. Attempting removal, false reassurance, or sedation without specialist input is inappropriate.
Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?
- A. To promote oxygen intake.
- B. To strengthen the diaphragm.
- C. To strengthen the intercostal muscles.
- D. To promote carbon dioxide elimination.
Correct Answer: D
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and promoting CO2 elimination in emphysema. It does not directly increase oxygen intake or strengthen muscles.
The client with Hodgkin's disease undergoes an excisional cervical lymph node biopsy under local anesthesia. After the procedure, which does the nurse assess first?
- A. Vital signs.
- B. The incision.
- C. The airway.
- D. The neurologic signs.
Correct Answer: C
Rationale: After a cervical lymph node biopsy, the nurse should first assess the airway, as swelling or hematoma in the neck could compromise breathing. Vital signs, incision, and neurologic signs are assessed next.
A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.