Nokea
The nurse evaluates that the client correctly understands how to report signs and symptoms of bleeding when the client makes which of the following statements?
- A. Petechiae are large, red skin bruises.'
- B. Ecchymoses are large, purple skin bruises.'
- C. Emmum is an open cut on the skin.'
- D. Abrasions are small pinpoint red dots on the skin.'
Correct Answer: B
Rationale: Ecchymoses are large, purple bruises caused by bleeding under the skin, a common sign of thrombocytopenia. This statement shows correct understanding. Petechiae are small, pinpoint red dots, not large bruises; 'emmum' is not a medical term; and abrasions are superficial skin injuries, not bleeding signs.
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A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.
Bethanechol (Urecholine) has been ordered for a client with gastroesophageal reflux disease (GERD). The nurse should assess the client for which of the following adverse effects?
- A. Constipation.
- B. Urinary urgency.
- C. Hypertension.
- D. Dry oral mucosa.
Correct Answer: B
Rationale: Bethanechol, a cholinergic agent, can cause urinary urgency as an adverse effect due to its stimulation of smooth muscle contraction, including in the bladder.
The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?
- A. Assess the oral cavity each time mouth care is given and record observations.
- B. Use a soft toothbrush to brush the client's teeth after each meal.
- C. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours.
- D. Rinse the client's mouth with mouthwash several times a day.
Correct Answer: B
Rationale: Using a soft toothbrush after meals is an effective and safe method for providing oral hygiene, promoting cleanliness without causing trauma.
A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
- A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
- B. Administer oxygen via nasal cannula.
- C. Offer pain medication for the chest heaviness.
- D. Inform the physician of the chest heaviness.
Correct Answer: A
Rationale: Assessing the characteristics of chest heaviness clarifies whether it is cardiac (e.g., angina) or non-cardiac, guiding further actions like oxygen or physician notification.
The physician prescribes sulfasalazine (Azulfidine) for the client with ulcerative colitis to continue taking at home. Which instruction should the nurse give the client about taking this medication?
- A. Avoid taking it with food.
- B. Take the total dose at bedtime.
- C. Take it with a full glass (240 mL) of water.
- D. Stop taking it if urine turns orange-yellow.
Correct Answer: C
Rationale: Sulfasalazine should be taken with a full glass of water to ensure proper absorption and to prevent gastrointestinal irritation. It can be taken with food to reduce stomach upset, the dose is typically spread out during the day, and orange-yellow urine is a harmless side effect. CN: Pharmacological and parenteral therapies; CL: Synthesize