Nokea
The client with acute leukemia and the health care team establish mutual client outcomes of improved tidal volume and activity tolerance. Which measure would be least likely to promote outcome achievement?
- A. Ambulating in the hallway.
- B. Sitting up in a chair.
- C. Lying in bed and taking deep breaths.
- D. Using a stationary bicycle in the room.
Correct Answer: C
Rationale: Improving tidal volume and activity tolerance requires active movement to enhance lung expansion and stamina. Ambulating, sitting up, and using a stationary bicycle promote these outcomes. Lying in bed, even with deep breaths, is passive and least effective.
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The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, 'I'm upset because I know I won't be able to have children now that I have an ileostomy.' Which of the following would be the best response for the nurse?
- A. Many women with an ileostomy can still have children; let's discuss your concerns with your doctor.
- B. Having an ileostomy does prevent pregnancy, but you can explore adoption.
- C. This is a common feeling; would you like to talk more about it?
- D. I'll RAW arrange for a counselor to discuss your fertility options.
Correct Answer: A
Rationale: The nurse should reassure the client that many women with ileostomies can still have children and offer to discuss this with the doctor, addressing the misconception directly. The other options either reinforce the misconception, avoid the concern, or defer without providing immediate support. CN: Psychosocial adaptation; CL: Synthesize
Which of the following is an appropriate expected outcome for a client recovering from a total laryngectomy? The client will:
- A. Regain the ability to taste and smell food.
- B. Demonstrate appropriate care of the gastrostomy tube.
- C. Communicate feelings about body image changes.
- D. Demonstrate sterile suctioning technique for stoma care.
Correct Answer: C
Rationale: Communicating feelings about body image changes is an appropriate psychosocial outcome post-laryngectomy, addressing adaptation to altered appearance. Taste and smell may be impaired long-term. Gastrostomy tubes are not always required. Sterile suctioning is a nursing task, not a client outcome.
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.
The nurse is assessing a client with macular degeneration. Identify the illustration that best depicts what clients with this disorder typically see
- A. degeneration-1.png
- B. degeneration-2.png
- C. degeneration-3.png
- D. degeneration-4.png
Correct Answer: C
Rationale: In macular degeneration the center vision is blackened out and only the outer visual fields are clear.
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.