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The client tells the preoperative nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response?
- A. Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken.
- B. Tell the client that she will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up.
- C. Explain to the client that she will have a premedication that will make her sleep before she goes to surgery and she won't need to hear.
- D. Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery.
Correct Answer: D
Rationale: Calling the surgery unit to discuss the client's need for a hearing aid ensures her communication needs are addressed while adhering to surgical safety protocols. This action balances patient advocacy with policy considerations.
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The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit?
- A. I can use heat and cold as often as I want.'
- B. With heat, I should apply it for no longer than 20 minutes at a time.'
- C. Heat-producing liniments can be used with other heat devices.'
- D. Ten to 15 minutes per application is the maximum time for cold applications.'
Correct Answer: A
Rationale: Frequent or prolonged use of heat and cold without guidance can cause tissue damage. The other statements reflect appropriate understanding of time limits and safe use.
The nurse has reinforced education at a conference on intramuscular (IM) injections. Which of the following statements by the participant would indicate a correct understanding of the teaching?
- A. "Aspiration before injection of IM medications is no longer universally recommended."
- B. "The deltoid muscle provides slower absorption rates than gluteal sites."
- C. "To ease a client's anxiety, inform the client that an IM injection will not hurt."
- D. "The dorsogluteal muscle is recommended as a site for IM injections."
Correct Answer: A
Rationale: Aspiration is not universally recommended for IM injections due to lack of evidence supporting its necessity.
A client with terminal cancer is transitioning to hospice care. The nurse should prioritize which of the following in the care plan?
- A. Aggressive pain management.
- B. Curative chemotherapy.
- C. Nutritional supplementation.
- D. Physical therapy.
Correct Answer: A
Rationale: Aggressive pain management is the priority in hospice care to ensure comfort and quality of life for a client with terminal cancer.
The nurse is monitoring a client post-insertion of a nasogastric tube for an intestinal obstruction. Which finding indicates the tube is functioning correctly?
- A. Clear, watery output.
- B. Bright red blood in the drainage.
- C. No output for 12 hours.
- D. Thick, mucus-like drainage.
Correct Answer: A
Rationale: Clear, watery output from a nasogastric tube indicates it is effectively decompressing the intestine by removing fluid and gas. Bright red blood suggests bleeding, no output may indicate a blockage, and thick drainage is not typical. CN: Physiological adaptation; CL: Evaluate
A client with colon cancer is having a barium enema. The nurse should instruct the client to take which of the following after the procedure is completed?
- A. Laxative.
- B. Anticholinergic.
- C. Antacid.
- D. Demulcent.
Correct Answer: A
Rationale: After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe mucous membranes of the gastrointestinal tract and are used to treat diarrhea. CN: Reduction of risk potential; CL: Synthesize