Nokea
The client is to take nothing by mouth after 4 a.m. The nurse recognizes that the client has deficient knowledge when he states that he:
- A. Ate a gelatin dessert at 3:30 a.m.
- B. Brushed his teeth at 4:00 a.m. but did not swallow.
- C. Held a cold washcloth against his lips.
- D. Smoked a cigarette at 6:00 a.m.
Correct Answer: D
Rationale: Smoking after 4 a.m. violates the nothing-by-mouth (NPO) order, as it introduces substances into the body and can affect anesthesia safety. The other actions either comply with NPO (brushing teeth without swallowing, holding a washcloth) or occurred before the cutoff (gelatin at 3:30 a.m.).
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A client with bladder cancer receives intravesical chemotherapy. The nurse should:
- A. Monitor for hematuria.
- B. Restrict fluids.
- C. Administer pain medication.
- D. Encourage bed rest.
Correct Answer: A
Rationale: Hematuria is a potential side effect of intravesical chemotherapy, requiring monitoring.
Which of the following home care instructions would be appropriate for a client with a laryngectomy?
- A. Perform mouth care every morning and evening.
- B. Provide adequate humidity in the home.
- C. Maintain a soft, bland diet.
- D. Limit physical activity to shoulder and neck exercises.
Correct Answer: B
Rationale: Adequate humidity prevents stoma crusting and maintains airway moisture. Mouth care frequency may need to be higher. Diet should be tailored to swallowing ability, not necessarily soft or bland. Physical activity should be encouraged, not limited, unless contraindicated.
The nurse is planning care for a client who has returned to the medical-surgical unit following repair of an aortic aneurysm. The nurse first should assess the client for:
- A. Alteration in renal perfusion
- B. Electrolyte imbalance
- C. Ineffective coping
- D. Wound infection
Correct Answer: A
Rationale: Post-aortic aneurysm repair, assessing renal perfusion is critical, as the surgery may involve clamping the aorta, risking renal ischemia. Reduced urine output or elevated creatinine indicates renal compromise. Electrolyte imbalance, coping, and infection are secondary concerns.
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate?
- A. Maintaining an upright position.
- B. Restricting the diet to liquids until swallowing improves.
- C. Introducing foods on the unaffected side of the mouth.
- D. Keeping distractions to a minimum.
Correct Answer: B
Rationale: Restricting the diet to liquids increases aspiration risk, as liquids are harder to control. Upright positioning, using the unaffected side, and minimizing distractions reduce aspiration risk.
A client with detachment of the retina is to patch both eyes. The expected outcome of patching is to:
- A. Reduce rapid eye movements.
- B. Decrease the irritation caused by light entering the damaged eye.
- C. Protect the injured eye from infection.
- D. Rest the eyes to promote healing.
Correct Answer: A
Rationale: Patching both eyes reduces rapid eye movements, which could worsen retinal detachment by preventing further stress on the retina.