Nokea
The nurse has given instructions about site care to a hemodialysis client who had an implantation of an arteriovenous (AV) fistula in the right arm. Which statement by the client indicates a need for further teaching?
- A. I will need to sleep on my right side.
- B. It's important that I don't carry heavy objects with the right arm.
- C. I will perform range-of-motion exercises routinely on my right arm.
- D. It's important that I report any right arm redness or drainage at the site.
Correct Answer: A
Rationale: Routine instructions to the client with an AV fistula, graft, or shunt include avoiding sleeping with the body weight on the extremity with the access site, avoiding carrying heavy objects or compressing the extremity that has the access site, performing routine range-of-motion exercises of the affected extremity, and reporting signs and symptoms of infection.
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The home care nurse provides instructions about the management of pruritus to a client diagnosed with jaundice. Which statement made by the client suggests to the nurse that the client needs further teaching?
- A. I need to wear loose cotton clothing.
- B. A tepid water bath should help stop the itching.
- C. Keeping the house warmer is likely to lessen the itching
- D. I need to take the prescribed antihistamines as I'm supposed to.
Correct Answer: C
Rationale: Pruritus is caused by the accumulation of bile salts in the skin and results from obstructed biliary excretion. The client would be instructed to keep the house temperature cool in order to minimize the itching. The client should avoid the use of alkaline soap, and he or she (client) should wear loose, soft, cotton clothing. Antihistamines may relieve the itching, as will tepid water and emollient baths.
A client with a short leg plaster cast reports intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which statement by the client indicates an understanding of the measures used to relieve the itching?
- A. I can use the blunt part of a ruler to scratch the area.
- B. I can trickle small amounts of water down inside the cast.
- C. I need to obtain assistance when placing an object into the cast for the itching.
- D. I can use a hair dryer on the low setting and allow the air to blow into the cast.
Correct Answer: D
Rationale: Itching is a common complaint of clients with casts. Objects should not be put inside a cast because of the risk of scratching the skin and providing a point of entry for bacteria. A plaster cast can break down when wet. Therefore, the best way to relieve itching is with the forceful injection of air inside the cast.
During a health assessment the nurse provides instructions to a client regarding the testicular self-examination (TSE). Which statement by the client indicates that the client needs further teaching regarding TSE?
- A. I know to report any small lumps.
- B. I should examine myself every 2 months.
- C. I should examine myself after I take a warm shower.
- D. I know it's normal to feel something that is cord-like in the back.
Correct Answer: B
Rationale: TSE should be performed every month. Small lumps or abnormalities should be reported. The spermatic cord finding is normal. After a warm bath or shower, the scrotum is relaxed, which makes it easier to perform TSE.
A client diagnosed with acquired immunodeficiency syndrome (AIDS) is reporting fatigue. The nurse educates the client on ways to conserve energy. Which statement indicates that the teaching was effective?
- A. Bathe before eating breakfast.
- B. Sit for as many activities as possible.
- C. Stand in the shower instead of taking a bath.
- D. Group all tasks to be performed early in the morning.
Correct Answer: B
Rationale: The client is taught to conserve energy by sitting for as many activities as possible, including dressing, shaving, preparing food, and ironing. The client should also sit in a shower chair instead of standing while showering. The client needs to prioritize activities such as eating breakfast before bathing, and the client should intersperse each major activity with a period of rest.
A client has been prescribed a clonidine patch, and the nurse has instructed the client regarding the use of the patch. Which client statement indicates a need for further teaching?
- A. I intend to change the patch every 7 days.
- B. I need to trim the patch if an edge becomes loose.
- C. It's important to put the patch on a hairless site on my torso.
- D. It's alright to leave the patch in place during bathing or showering.
Correct Answer: B
Rationale: The clonidine patch should not be trimmed because it will alter the medication dose. If it becomes slightly loose, it should be covered with an adhesive overlay from the medication package. If it becomes very loose or falls off, it should be replaced. It is changed every 7 days, and is left in place when bathing or showering. The clonidine patch should be applied to a hairless site on the torso or the upper arm. The patch is discarded by folding it in half with the adhesive sides together.