Nokea
The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client?
- A. An appropriate form must be signed, verifying refusal
- B. Complications, including death, could result
- C. The client will be billed for the equipment regardless
- D. The surgeon will be informed of the refusal
Correct Answer: B
Rationale: SCDs prevent deep vein thrombosis (DVT) post-surgery, a potentially fatal complication. Communicating the risk of complications, including death (B), is critical to emphasize the importance of compliance. Signing a refusal form (A), billing (C), or informing the surgeon (D) are secondary to ensuring the client understands the serious risks.
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The nurse has reinforced teaching with the parent of a 3-year-old client who has acute diarrhea. Which of the following statements by the parent would require follow-up?
- A. I will apply a skin barrier cream to my child’s diaper area until the diarrhea subsides.
- B. I will encourage my child to drink small amounts of fluids at frequent intervals.
- C. I will feed my child a diet of bananas, rice, applesauce, and toast for the next few days.
- D. I will return to the clinic if I notice a decrease in my child’s urine output.
Correct Answer: C
Rationale: The BRAT diet (C) is outdated and may lack nutrients, risking prolonged recovery. Skin barrier cream (A), frequent fluids (B), and monitoring urine output (D) are appropriate for preventing skin breakdown, dehydration, and detecting complications.
A person who has psoriasis is seen in the clinic. The lesions are covered with coal tar. Which instruction should the nurse give the client?
- A. Call if you have nausea and vomiting.'
- B. Protect the area from sunlight for 24 hours.'
- C. Wash off the solution after six to eight hours.'
- D. Call if your skin looks dark during the treatment.'
Correct Answer: B
Rationale: Coal tar increases photosensitivity; protecting the area from sunlight for 24 hours prevents burns. Nausea, washing off, or skin darkening are not primary concerns.
The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?
- A. Low tar cigarettes are less harmful during pregnancy
- B. There is a relationship between smoking and low birth weight
- C. The placenta serves as a barrier to nicotine
- D. Moderate smoking is effective in weight control
Correct Answer: B
Rationale: There is a relationship between smoking and low birth weight. Smoking reduces placental blood flow, contributing to fetal hypoxia and low birth weight.
An adolescent client has been hospitalized for 2 months for an eating disorder. She asks the nurse what to tell her classmates about her long absence. The nurse can best help the client by:
- A. Having her practice changing the subject when asked personal questions
- B. Helping her invent a believable explanation for her absence
- C. Engaging her in role playing activities that are likely to occur
- D. Encouraging her to share her experiences with those who ask
Correct Answer: C
Rationale: Role-playing helps the client prepare for social interactions, building confidence in handling questions about her absence.
The nurse is reinforcing teaching of proper foot care to a client with diabetes mellitus. Which statement by the client indicates the need for further teaching?
- A. I will apply lanolin to my feet to prevent dry skin
- B. I will avoid applying a heating pad directly to my feet
- C. I will test the water with a thermometer before bathing
- D. I will wear sandals instead of sneakers to prevent moisture.
Correct Answer: D
Rationale: Sandals (D) expose feet to injury, increasing infection risk in diabetes. Lanolin (A), avoiding heating pads (B), and testing water (C) are correct to prevent skin breakdown and burns.