Nokea
Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as ordered. The nurse should do which of the following first?
- A. Ask the client's wife to assist with the daily fluid intake to at least 2,500 mL.
- B. Respect the client's wishes and turn the client from side-to-side more frequently.
- C. Assess the client's reasons for refusing to deep breathe and cough.
- D. Explain the risks of not expanding the lungs and why the exercise is important.
Correct Answer: C
Rationale: Assessing the client's reasons for refusal identifies barriers (e.g., pain, fear), allowing tailored interventions to encourage compliance with deep-breathing exercises.
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A client post-cystoscopy is discharged. The nurse should instruct to:
- A. Resume normal activity.
- B. Avoid fluids for 24 hours.
- C. Expect blue urine.
- D. Take antibiotics for a week.
Correct Answer: A
Rationale: Normal activity can resume post-cystoscopy unless complications arise.
A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During preoperative teaching, the nurse teaches the client how to do deep breathing exercises after surgery by telling the client to:
- A. Sit in an upright position and take a deep breath.'
- B. Hold your abdomen firmly with a pillow and take several deep breaths.'
- C. Tighten your stomach muscles as you inhale and relax them as you exhale.'
- D. Raise your shoulders to expand your chest.'
Correct Answer: B
Rationale: Holding the abdomen with a pillow during deep breathing reduces pain and supports the surgical site post-adrenalectomy.
The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). The nurse should assess the client further for signs of:
- A. Aortic aneurysm
- B. Deep vein thrombosis (DVT) in the left leg
- C. I.V. drug abuse
- D. Intermittent claudication
Correct Answer: B
Rationale: Left leg pain, positive Homans' sign (pain on dorsiflexion), and low-grade fever suggest deep vein thrombosis (DVT). Further assessment for swelling, redness, or warmth confirms this. Aortic aneurysm, I.V. drug abuse, and claudication present differently.
A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which of the following should be the primary focus of nursing care for this client?
- A. Providing activities of daily living on the time schedule that the client wishes.
- B. Offering foods that the client enjoys in order to increase the intake of calories.
- C. Decreasing cardiac demands by promoting rest.
- D. Listening to concerns about the hospitalization.
Correct Answer: C
Rationale: Thalassemia, a hemolytic anemia, causes increased cardiac workload due to chronic anemia and tissue hypoxia. Promoting rest is the primary focus to decrease cardiac demands and prevent complications like heart failure. While client preferences, nutrition, and emotional support are important, reducing cardiac strain is critical.
The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. The nurse should:
- A. Allow the client to keep the eye drops at the bedside and use as prescribed on the bottle.
- B. Place the eye drops in the medication drawer and administer as labeled on the bottle.
- C. Explain to the client that the physician will write an order for the eye drops to be used at the hospital.
- D. Ask the client's wife to assist the client in administering the eye drops while the client is in the hospital.
Correct Answer: C
Rationale: The nurse should explain that the physician needs to write an order for the eye drops to ensure they are appropriate and safe for hospital use, maintaining medication safety protocols.