Nokea
The client with tuberculosis is to be discharged home with community health nursing follow-up. Of the following nursing interventions, which should have the highest priority?
- A. Offering the client emotional support.
- B. Teaching the client about the disease and its treatment.
- C. Coordinating various agency services.
- D. Assessing the client's environment for sanitation.
Correct Answer: B
Rationale: Teaching about the disease and treatment is the priority to ensure adherence to the lengthy regimen, preventing relapse or resistance. Emotional support, agency coordination, and sanitation are important but secondary.
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A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 mL/hour. How long would this transfusion take to infuse?
- A. 2 hours.
- B. 4 hours.
- C. 6 hours.
- D. 8 hours.
Correct Answer: B
Rationale: A unit of packed red blood cells is approximately 250–300 mL. At 60 mL/hour, 240 mL (close to a unit) takes 240 ÷ 60 = 4 hours.
A 32-year-old female meets with the nurse on her first office visit since undergoing a left mastectomy. When asked how she is doing, the woman says her appetite is still not good, she is not getting much sleep because she doesn't go to bed until her husband is asleep, and she is really anxious to get back to work. Which of the following nursing interventions should the nurse explore to support the client's current needs?
- A. Call the physician to discuss allowing the client to return to work earlier.
- B. Suggest that the client learn relaxation techniques for help with her insomnia.
- C. Perform a nutritional assessment to assess for anorexia.
- D. Ask open-ended questions about sexuality issues related to her mastectomy.
Correct Answer: B
Rationale: Insomnia is a primary concern, and relaxation techniques can help improve sleep, addressing the client's emotional and physical recovery needs post-mastectomy.
The nurse is preparing to administer ear drops to a client who is six years old. The nurse should perform which action?
- A. Pull the ear pinna down and back
- B. Position the client on their side with the ear to be treated against a pillow
- C. Pull the ear pinna up and back
- D. Place cotton directly into the ear canal after ear drop administration
Correct Answer: C
Rationale: For children over 3 years, pulling the ear pinna up and back straightens the ear canal for proper administration.
A nurse is planning care for a client who underwent a percutaneous needle biopsy of the kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
- A. Assess the biopsy site.
- B. Take vital signs every hour.
- C. Assess urine for hematuria.
- D. Place the client in a prone position.
- E. Assess the client for chest pain.
Correct Answer: A,C,D
Rationale: Assessing the biopsy site, urine for hematuria, and placing the client prone help monitor for bleeding and promote hemostasis post-biopsy.
A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.