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The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:
- A. The bladder fills more rapidly because of the medication used for the epidural.
- B. Her level of consciousness is altered.
- C. The sensation of the bladder filling is diminished or lost.
- D. She is embarrassed to ask for the bedpan that frequently.
Correct Answer: C
Rationale: Epidural anesthesia can diminish bladder sensation, increasing the risk of urinary retention, so hourly voiding is encouraged.
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The nurse is completing the preoperative checklist on a client scheduled for surgery and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
- A. Call the surgeon and ask him to come see the client to clarify the information
- B. Explain the procedure and complications to the client
- C. Check in the physician's progress notes to see if understanding has been documented
- D. Check with the client's family to see if they understand the procedure fully
Correct Answer: A
Rationale: Informed consent requires that the client understands the procedure and its risks. If the client is unclear, the surgeon, as the primary provider, should clarify the information to ensure the client's understanding, as this is a legal and ethical requirement.
A mother asks the home health nurse for guidance on what foods are safe to give her child, who is on strict neutropenic precautions. The nurse looks at the mother's grocery list and advises her to avoid
- A. canned peaches.
- B. pasteurized whole milk.
- C. the fresh veggie tray.
- D. fresh bananas.
Correct Answer: C
Rationale: Neutropenic precautions require avoiding fresh, unprocessed foods (e.g., fresh veggies) due to bacterial risk. Canned, pasteurized, or peeled foods are safer.
A nurse is caring for a client who has just undergone an ileostomy procedure. The nurse expects how much drainage from the ileostomy during the first 24 hours post-op?
- A. 650 mL
- B. 800 mL
- C. 1,500 mL
- D. 3,500 mL
Correct Answer: B
Rationale: Ileostomy drainage in the first 24 hours post-op is typically 500-1,000 mL due to liquid stool output. 800 mL is the most reasonable estimate.
A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?
- A. TB skin test
- B. Rubella vaccine
- C. ELISA test
- D. Chest x-ray
Correct Answer: B
Rationale: The rubella vaccine is contraindicated in clients with egg allergies, as it may be grown in egg-based cultures.
A 22-year-old pregnant client is diagnosed with autoimmune hemolytic anemia. The nurse anticipates immediate treatment with
- A. IgA.
- B. IgG.
- C. IgE.
- D. IgD.
- E. None
Correct Answer: E
Rationale: Autoimmune hemolytic anemia in pregnancy is typically treated with corticosteroids or IVIG (containing IgG), but IgG alone isn’t administered. None of the options are correct.