The charge nurse is formulating a discharge teaching plan fo...

The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:

A. Teaching the client to report a nosebleed
B. Instructing the client to maintain strict bed rest
C. Telling the client to notify the doctor of pedal edema
D. Advising the client to avoid sodium sources in the diet

Correct Answer: A

Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.

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The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?

A. Stage I
B. Stage II
C. Stage III
D. Stage IV
E. unstageable

Correct Answer: E

Rationale: Eschar covering the wound bed makes it unstageable, as the depth cannot be assessed until debridement.

A homeless client has been admitted to the hospital for observation, and he does not speak any English. The nurse does not know any of the client's medical history, but he is grimacing and looks to be in pain. The nurse should

A. use nonverbal communication such as pointing and gestures.
B. call for the hospital interpreter services.
C. give the client pen and paper and encourage him to draw.
D. wait to see if any friends or family visit the client who may be able to help.

Correct Answer: B

Rationale: An interpreter ensures accurate communication for assessing pain and history, respecting patient needs and safety.

A client with recurrent episodes of gout has been advised to eat a low-purine diet. Which of the following foods should the nurse advise him to limit or avoid? Select all that apply.

A. Liver.
B. Sardines.
C. Wine.
D. Low-fat yogurt.
E. Beef broth.
F. Potatoes.

Correct Answer: A,B,E

Rationale: High-purine foods like liver (A), sardines (B), and beef broth (E) should be limited to reduce gout flare-ups. Wine (C), low-fat yogurt (D), and potatoes (F) are low in purines and generally safe.

While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:

A. Place the implant in a biohazard bag and return it to the lab
B. Give the client a pair of gloves and ask her to reinsert the implant
C. Use tongs to pick up the implant and return it to a lead-lined container
D. Discard the implant in the commode and double-flush

Correct Answer: C

Rationale: Radioactive implants must be handled with tongs and placed in a lead-lined container to minimize radiation exposure, per safety protocols.

The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?

A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
B. A positive C reactive protein in a client with rheumatic fever
C. A hematocrit of 52% in a client with gastroenteritis
D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin

Correct Answer: D

Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.