Nokea
The nurse is applying a hand mitt restraint for a client with pruritis (see figure). The nurse should be:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: A physician's order is required for restraints to ensure legal and ethical use, prioritizing patient safety and preventing scratching in pruritus.
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After a client who has had a laparoscopic cholecystectomy receives discharge instructions, which of the following client statements would indicate that the teaching has been successful? Select all that apply.
- A. I can resume my normal diet when I want.
- B. I need to avoid driving for about 4 weeks.
- C. I may experience some pain in my right shoulder.
- D. I should spend 2 to 3 days in bed before resuming activity.
- E. I can wash the puncture site with mild soap and water.
Correct Answer: C,E
Rationale: Right shoulder pain (C) can occur due to referred pain from diaphragmatic irritation. Washing the puncture site with mild soap and water (E) is correct for hygiene. Resuming a normal diet immediately (A) is incorrect; a low-fat diet is advised. Avoiding driving for 4 weeks (B) is excessive; 1-2 weeks is typical. Bed rest for 2-3 days (D) is unnecessary as early ambulation is encouraged.
The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which lab serum that is a potential precipitating factor for hepatic encephalopathy?
- A. Aldosterone.
- B. Creatinine.
- C. Potassium.
- D. Protein.
Correct Answer: C
Rationale: Hypokalemia (C) increases ammonia production, precipitating hepatic encephalopathy. Aldosterone (A), creatinine (B), and protein (D) are not directly linked to this condition's onset.
A 60-year-old client with acute myeloid leukemia (AML) states that he overheard one of the other clients say that AML had a very poor prognosis. The client explains to the nurse that he had understood his doctor to say that he had a relatively good prognosis. Which is the nurse's best response?
- A. You must have misunderstood. Whom did you hear that from?'
- B. AML does have a very poor prognosis for poorly differentiated cells.'
- C. AML is the most common nonlymphocytic leukemia.'
- D. Your doctor stated your prognosis based on the differentiation of your cells.'
Correct Answer: D
Rationale: The prognosis for AML varies based on factors like cell differentiation, age, and genetics. The nurse should clarify that the doctor's prognosis was specific to the client's cell differentiation, reassuring him without dismissing his concerns. The other responses are either confrontational, overly general, or irrelevant.
A client who has had a total laryngectomy appears withdrawn and depressed. He keeps the curtain drawn, refuses visitors, and indicates a desire to be left alone. Which nursing intervention would have the threshold to be removed.
- A. Discussing his behavior with his wife to determine the cause.
- B. Exploring his future plans.
- C. Respecting his need for privacy.
- D. Encouraging him to express his feelings nonverbally and in writing.
Correct Answer: D
Rationale: Encouraging nonverbal or written expression allows the client to process emotions despite speech loss, addressing psychological needs. Discussing with his wife breaches confidentiality. Exploring future plans may be premature. Respecting privacy may reinforce withdrawal.
Which intervention is appropriate for a client on hemodialysis?
- A. Check fistula for a thrill.
- B. Restrict all fluids.
- C. Administer heparin post-dialysis.
- D. Encourage high-protein diet.
Correct Answer: A
Rationale: Checking for a thrill ensures fistula patency for dialysis.