Nokea
The client tells the nurse, 'I have pain in my left shoulder.' This is considered:
- A. Evaluation process
- B. Objective information
- C. Subjective information
- D. Complaining
Correct Answer: C
Rationale: Subjective information is provided by a person.
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A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
- A. Assessing the skin daily for breakdown
- B. Massaging any erythematous areas on the skin
- C. Changing incontinence pads as soon as they become soiled with urine or feces
- D. Performing range-of-motion exercises and turning and repositioning the client
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning enhances blood flow to tissues, reducing the risk of pressure ulcers by relieving pressure points. Assessing skin (A) is monitoring, not an intervention to improve perfusion. Massaging erythematous areas (B) can worsen tissue damage. Changing pads (C) prevents irritation but doesn’t directly improve perfusion.
The nurse is caring for a client with a history of a pneumothorax who is being discharged. The nurse should teach the client to:
- A. Resume heavy lifting
- B. Avoid swimming
- C. Report chest pain immediately
- D. Sleep on the affected side
Correct Answer: C
Rationale: Chest pain post-pneumothorax may indicate recurrence or complications, requiring immediate reporting. Heavy lifting and swimming are restricted, and sleeping position is not critical.
The nurse is caring for a client with a history of a hysterectomy. The client complains of hot flashes. The nurse should:
- A. Apply a heating pad
- B. Encourage fluid restriction
- C. Discuss hormone replacement therapy
- D. Administer acetaminophen
Correct Answer: C
Rationale: Hot flashes post-hysterectomy are due to hormonal changes. Discussing hormone replacement therapy with the physician is appropriate. Heating pads, fluid restriction, and acetaminophen are ineffective.
A nurse is preparing to mix and administer chemotherapy. What equipment would be unnecessary to obtain?
- A. Surgical gloves
- B. Luer lok fitting IV tubing
- C. Surgical hat cover
- D. Disposable long-sleeve gown
Correct Answer: C
Rationale: Surgical gloves, Luer lok tubing, and long-sleeve gowns are essential for safe chemotherapy administration to prevent exposure. A surgical hat cover (C) is not typically required unless in a sterile procedure.
Which of the following side effects is associated with androgen therapy?
- A. Gynecomastia
- B. Increased appetite
- C. Virilization
- D. Euphoria
Correct Answer: C
Rationale: Androgen therapy promotes male secondary sexual characteristics leading to virilization (e.g. deepened voice facial hair). Gynecomastia is associated with estrogen and increased appetite or euphoria are not typical side effects of androgens.