Nokea
The mother of a male child with cystic fibrosis tells the nurse that she hopes her son's children won't have the disease. The nurse is aware that:
- A. There is a 25% chance that his children will have cystic fibrosis.
- B. Most of the males with cystic fibrosis are sterile.
- C. There is a 50% chance that his children will be carriers.
- D. Most males with cystic fibrosis are capable of having children, so genetic counseling is advised.
Correct Answer: B
Rationale: Most males with cystic fibrosis are sterile due to congenital absence of the vas deferens, significantly reducing the likelihood of having biological children.
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The nurse is working with another nurse and a patient care assistant. Which of the following clients should be assigned to the registered nurse?
- A. A client 2 days post-appendectomy
- B. A client 1 week post-thyroidectomy
- C. A client 3 days post-splenectomy
- D. A client 2 days post-thoracotomy
Correct Answer: D
Rationale: A post-thoracotomy patient requires RN monitoring for respiratory complications.
The nurse is reviewing the lab results of four clients. Which finding should be reported to the physician?
- A. A client with chronic renal failure with a serum creatinine of 5.6 mg/dL
- B. A client with rheumatic fever with a positive C reactive protein
- C. A client with gastroenteritis with a hematocrit of 52%
- D. A client with epilepsy with a white cell count of 3,800 mm³
Correct Answer: C
Rationale: A hematocrit of 52% in gastroenteritis suggests dehydration, which requires immediate reporting.
The nurse is caring for a client who is disoriented. To avoid using restraints, the nurse chooses alternative methods to help keep the client oriented. Which interventions would the nurse use for this client? Select all that apply.
- A. maintain normal toileting routines
- B. minimize visitation so that the client may rest
- C. evaluate the client's medications for side effects
- D. keep familiar items such as family pictures near the bedside
- E. use calendars and clocks to orient the client to the date and time
- F. place the client in a room near the end of the hall to minimize noise
Correct Answer: A,C,D,E
Rationale: Toileting routines, medication review, familiar items, and calendars/clocks promote orientation. Minimizing visitation may isolate the client, and room placement is less relevant.
The nurse is preparing a client with gastroesophageal reflux disease (GERD) for discharge. The nurse should tell the client to:
- A. Eat a small snack before bedtime
- B. Sleep on his right side
- C. Avoid carbonated beverages
- D. Increase his intake of citrus fruits
Correct Answer: C
Rationale: Carbonated beverages can increase stomach pressure and worsen GERD symptoms by promoting acid reflux.
The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to:
- A. Maintain a patent airway
- B. Perform meticulous oral care every 2 hours
- C. Ensure that the incisional area is kept as dry as possible
- D. Assess the client frequently for pain
Correct Answer: A
Rationale: Maintaining a patent airway is critical post-oral surgery due to the risk of swelling or bleeding obstructing the airway.