Nokea
Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time?
- A. Teaching how to prevent hip flexion.
- B. Demonstrating coughing and deep-breathing techniques.
- C. Showing the client what an actual hip prosthesis looks like.
- D. Assessing the client's fears about the procedure.
Correct Answer: A
Rationale: Preventing hip flexion is critical to avoid dislocation post-surgery.
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A client with an ileal conduit asks how to reduce pouch odor. The nurse suggests:
- A. Avoiding broccoli.
- B. Using bleach to clean the pouch.
- C. Drinking less water.
- D. Applying powder to the stoma.
Correct Answer: A
Rationale: Odor-producing foods like broccoli should be avoided to minimize pouch odor.
The nurse is teaching a client and his family about the client's new diagnosis of hemochromatosis. Which of the following details should the nurse include?
- A. Hemochromatosis is an autoimmune disorder that affects the HFE gene.
- B. Individuals who are heterozygous for hemochromatosis rarely develop the disease.
- C. Individuals who are homozygous for hemochromatosis are carriers of hemochromatosis.
- D. Men are at greater risk for hemochromatosis.
Correct Answer: B,D
Rationale: Hemochromatosis is a genetic disorder caused by HFE gene mutations, not an autoimmune condition. Heterozygous individuals rarely develop the disease, as two mutated genes are typically required. Homozygous individuals have the disease, not just carriers. Men are at greater risk due to higher iron accumulation (women lose iron via menstruation). These points should be included in teaching.
Prior to being transported to the surgery suite, the nurse asks the client whether he has any allergies. The client responds, 'Doesn't anyone communicate with anyone? I have been asked that question over and over!' What is the nurse's best response?
- A. œI'm sorry! I just have to ask that question for the record.'
- B. œIt's an important question and we just have to check.'
- C. œYou will hear it again and again as you go through surgery.'
- D. œThis question is asked for verification and safety with each new phase of treatment.'
Correct Answer: D
Rationale: Explaining that repeated allergy checks are for safety and verification reassures the client while clarifying the purpose of the question. This response addresses the client's frustration and emphasizes the importance of the process.
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.
The nurse is teaching a client with osteoarthritis about assistive devices. Which device is most appropriate for ambulation?
- A. Standard cane.
- B. Wheelchair.
- C. Four-wheeled walker.
- D. Crutches.
Correct Answer: A
Rationale: A standard cane provides support and stability for clients with osteoarthritis during ambulation.