Nokea
The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, 'I will receive tissue from
- A. a tissue bank.
- B. a pig.
- C. my thigh.
- D. synthetic skin.
Correct Answer: C
Rationale: Autografts are done with tissue transplanted from the client's own skin.
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The nurse is caring for a client with a suspected stroke who is scheduled for a CT scan of the head. Which of the following assessments would be a priority for the nurse to make prior to the CT scan?
- A. Assess for a history of asthma
- B. Check the client’s blood glucose level
- C. Obtain a set of vital signs
- D. Verify whether the client has any allergies to contrast media
Correct Answer: D
Rationale: Allergies to contrast media are critical to assess before a CT scan to prevent anaphylaxis. Asthma, glucose, and vital signs are important but secondary to contrast safety.
The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, 'I don’t know why this is being reported. I told the health care provider (HCP) that it was an accident.' What is the best response by the nurse?
- A. A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then
- B. Did you ask the HCP why it is being reported?
- C. Reporting your child’s injuries is required by law. It is for your child’s safety and protection
- D. Your explanation of your child’s injuries does not seem plausible
Correct Answer: C
Rationale: Explaining that reporting is legally mandated for child safety is factual and nonjudgmental. Deferring to CPS, questioning the parent, or doubting their explanation may escalate tension or avoid responsibility.
The nurse talking with a client with polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I will drink plenty of water every day
- B. I should take a low-dose aspirin every day
- C. I need to have blood removed periodically
- D. I will continue taking my daily multivitamin with iron
Correct Answer: D
Rationale: Iron supplements can worsen polycythemia vera by increasing red blood cell production. Hydration, aspirin, and phlebotomy are appropriate management strategies.
The nurse is talking with a postpartum client about resuming sexual activity after childbirth. The client had an uncomplicated vaginal delivery 2 weeks ago. Which statement by the client requires follow-up?
- A. I do not need to use condoms to prevent pregnancy until my menses returns
- B. "I should avoid resuming sexual intercourse until my vaginal bleeding has stopped."
- C. I should expect to experience vaginal dryness and can use water-soluble lubricants
- D. I will try to feed my baby before my partner and I engage in sexual activity
Correct Answer: A
Rationale: Ovulation can occur before menses returns, so condoms are needed to prevent pregnancy. Vaginal dryness is common, and feeding before sex reduces interruptions, both correct.
What should the nurse do when ambulating a client who has a portable wound drainage system?
- A. Remove the drainage catheter during ambulation
- B. Fasten the collection device below the wound
- C. Completely empty the collection device before ambulating
- D. Disconnect the suction apparatus from the client before ambulating
Correct Answer: B
Rationale: Fastening the drainage device below the wound promotes gravity-dependent drainage, preventing reflux and infection during ambulation.