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The nurse has given the client with a nephrostomy tube instructions to follow after hospital discharge to prevent complications. The nurse determines that the client understands the instructions if the client verbalizes the need to drink how many glasses of water per day?
- A. 1 to 3
- B. 6 to 8
- C. 10 to 12
- D. 14 to 16
Correct Answer: B
Rationale: The client with a nephrostomy tube needs to have adequate fluid intake to dilute urinary particles that could cause calculus and provide good mechanical flushing of the kidney and the tube. The nurse encourages the client to take in 2000mL of fluid per day, which is roughly equivalent to 6 to 8 glasses of water. One to three glasses of water is an inadequate amount. Amounts over 10 glasses of water could distend the renal pelvis.
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A clinic nurse provides information to a married couple regarding measures to prevent infertility. Which statement made by the husband indicates the need for further education?
- A. We need to eat a nutritious diet.'
- B. We need to avoid the excessive intake of alcohol.'
- C. We need to decrease exposure to environmental hazards.'
- D. I need to maintain warmth to my scrotum by taking hot baths frequently.'
Correct Answer: D
Rationale: Keeping the testes cool by avoiding hot baths and tight clothing appears to improve the sperm count. Avoiding factors that depress spermatogenesis (such as the use of drugs, alcohol, and marijuana), maintaining good nutrition, and limiting exposure to occupational and environmental hazards are vital components of preventing infertility.
The nurse has completed discharge teaching with a client who has had surgery for lung cancer. The nurse determines that the client needs additional teaching about the elements of home management if the client verbalizes the need to follow which instruction?
- A. Avoid exposure to crowds.
- B. Deal with any increases in pain independently.
- C. Sit up and lean forward to breathe more easily.
- D. Call the primary health care provider if shortness of breath occurs.
Correct Answer: B
Rationale: Clients post-lung cancer surgery should not manage increased pain independently, as it may indicate complications requiring medical attention. Avoiding crowds, sitting up to breathe easier, and reporting shortness of breath are appropriate home management strategies.
A client with a compound (open) fracture of the radius has a plaster cast applied in the emergency department. The nurse provides home care instructions and tells the client to seek medical attention if which finding occurs?
- A. Numbness and tingling are felt in the fingers.
- B. The cast feels heavy and damp after 24 hours of application.
- C. The entire cast feels warm during the first 24 hours after application.
- D. Slightly bloody drainage is noted on the cast during the first 6 hours after application.
Correct Answer: A
Rationale: A limb encased in a cast is at risk for nerve damage and diminished circulation from increased pressure caused by edema. Signs/symptoms of increased pressure from the cast include numbness, tingling, and increased pain. A cast can take up to 48 hours to dry and generates heat while drying. Some drainage may occur initially with a compound (open) fracture.
The nurse is demonstrating colostomy care to a client with a newly created colostomy. The nurse demonstrates the correct cutting of the appliance by making the circle how much larger than the client's stoma?
- A. 1/8 inch
- B. 1/4 inch
- C. 1/2 inch
- D. 1 inch
Correct Answer: A
Rationale: The size of the opening for the appliance is generally cut 1/8 inch larger than the size of the client's stoma. This minimizes the amount of exposed skin but does not put pressure on the stoma. The larger sizes leave too much skin area exposed for irritation by gastrointestinal contents.
The nurse has provided home-care instructions to a client who is taking lithium carbonate. Which client statement indicates that the client understands the prescribed regimen?
- A. I will restrict my water intake.
- B. I will make sure that my diet contains salt.
- C. I will keep my medication in the refrigerator.
- D. I will be careful to avoid eating foods high in potassium.
Correct Answer: B
Rationale: Lithium is a mood stabilizer used to treat bipolar disorder. It replaces sodium ions in the cells and induces the excretion of sodium and potassium from the body. Client teaching includes the maintenance of sodium intake in the daily diet and increased fluid intake (at least 1 to 1½ L per day) during maintenance therapy. Lithium is stored at room temperature and protected from light and moisture.