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The client asks the nurse, 'Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?' On which of the following should the nurse base the response?
- A. The need to remove as much of the leg as possible.
- B. The adequacy of the blood supply to the tissues.
- C. The ease with which a prosthesis can be fitted.
- D. The client's ability to walk with a prosthesis.
Correct Answer: B
Rationale: The extent of amputation depends on tissue viability, determined by blood supply intraoperatively.
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The nurse is teaching a client how to manage a nosebleed. Which of the following instructions would be appropriate to give the client?
- A. Tilt your head backward and pinch your nose.
- B. Lie down flat and place an ice compress over the bridge of the nose.
- C. Blow your nose gently with your neck
- D. Sit down, lean forward, and pinch the soft portion of your nose.
Correct Answer: D
Rationale: Sitting and leaning forward while pinching the soft portion of the nose compresses the bleeding site and prevents blood from flowing down the throat. Tilting backward can cause swallowing of blood. Lying flat is not recommended. Blowing the nose can worsen bleeding.
What is the nurse's best response to a client with MS experiencing fatigue?
- A. Limit all activities.
- B. Schedule rest periods.
- C. Increase fluid intake.
- D. Avoid all exercise.
Correct Answer: B
Rationale: Scheduling rest periods helps manage fatigue while supporting activity in multiple sclerosis.
The client's identification armband was removed to start an I.V. line as a part of the preoperative preparation. The transport team has arrived to transport the client to the operating room. The nurse notices that the client's identification band is not on his wrist. What is the nurse's best response?
- A. Send the removed armband with the chart and the client to the operating room.
- B. Place a new identification armband on the client's wrist before transport.
- C. Tape the cut armband back onto the client's wrist.
- D. Send the client without an armband because she can verbally identify herself.
Correct Answer: B
Rationale: Placing a new identification armband ensures accurate client identification during transport and surgery, maintaining safety and compliance with protocol.
A client with disseminated intravascular coagulation develops ventricular microvascular thrombosis. The nurse should assess the client for:
- A. Hemoptysis.
- B. Focal ischemia.
- C. Petechiae.
- D. Hematuria.
Correct Answer: B
Rationale: Microvascular thrombosis in DIC can cause focal ischemia by obstructing small vessels, leading to tissue damage in organs like the kidneys or brain. Hemoptysis, petechiae, and hematuria are related to bleeding, not thrombosis.
Which finding indicates a properly functioning ileal conduit?
- A. Clear urine output.
- B. Mucus in the urine.
- C. Dry stoma site.
- D. No urine output.
Correct Answer: B
Rationale: Mucus in the urine is normal due to the intestinal segment used in the conduit.