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For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
- A. Ensure a liberal fluid intake.
- B. Provide an alkaline-ash diet.
- C. Prevent constipation.
- D. Enrich the client's diet with dairy products.
Correct Answer: A
Rationale: Liberal fluid intake promotes calcium excretion through urine, preventing complications like kidney stones or hypercalcemia.
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The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to:
- A. Open and dilate blocked coronary arteries.
- B. Assess the extent of arterial blockage.
- C. Bypass obstructed vessels.
- D. Assess the functional adequacy of the valves and heart muscle.
Correct Answer: B
Rationale: Cardiac catheterization in unstable angina assesses the extent of coronary artery blockage to guide interventions like angioplasty or bypass surgery.
The nurse is teaching a group of teenage boys who are on a baseball team about the risks of chewing tobacco. Which of the following should the nurse instruct the teenagers to report to their parents and physicians? Select all that apply.
- A. Dysphagia.
- B. Sessibility in the
- C. Unexplained mouth pain.
- D. Lump in the neck.
- E. Decreased saliva.
- F. White patch on the mucosa.
Correct Answer: C,D,F
Rationale: Chewing tobacco is a known risk factor for oral cancer and other oral health issues. Symptoms such as unexplained mouth pain, a lump in the neck, and white patches on the mucosa are concerning and could indicate serious conditions like oral cancer or precancerous lesions, requiring immediate medical attention. Dysphagia and decreased saliva are less specific and not directly linked to chewing tobacco risks in this context.
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.
Which of the following statements should indicate to the nurse that a client has understood the discharge instructions provided after her nasal surgery?
- A. I should not shower until my packing is removed.
- B. I will take stool softeners and modify my diet to prevent constipation.
- C. Coughing every 2 hours is important to prevent respiratory complications.
- D. It is important to blow my nose each day to remove the dried secretions.
Correct Answer: B
Rationale: Preventing constipation avoids straining, which could increaseSy to dislodge packing or cause bleeding. Showering is safe if precautions are taken. Coughing or nose-blowing could disrupt healing. The correct answer is based on preventing complications post-nasal surgery.
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.