Nokea
The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home?
- A. Positive gag reflex
- B. Hypoactive bowel sounds
- C. Blood pressure 90/60 mm Hg
- D. Incisional pain '2' on a scale of 0 to 10
- E. Urinary output of 240 mL since surgery
Correct Answer: A,D,E
Rationale: A positive gag reflex indicates airway protection, mild incisional pain (2/10) suggests adequate pain control, and sufficient urinary output (240 mL) indicates renal function, all supporting discharge readiness. Low blood pressure (90/60 mm Hg) suggests instability, and hypoactive bowel sounds are expected but not a discharge criterion.
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The nurse is providing patient teaching to the mother of a child with a banana allergy. The nurse would be most correct in informing the mother that this child is at an increased risk of developing an allergy to which of the following?
- A. Penicillin
- B. Cat dander
- C. Latex
- D. Peanuts
Correct Answer: C
Rationale: Banana allergy is associated with latex-fruit syndrome, increasing latex allergy risk. Penicillin, cat dander, and peanuts are unrelated.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
The nurse is caring for a client scheduled for surgery who is nothing by mouth (NPO) status. Which of the following prescription should the nurse clarify with the primary healthcare physician (PHCP)?
- A. Lispro insulin 5 units SubQ TID
- B. Glargine insulin 15 units SubQ QHS
- C. Vitamin B12 100 mcg IM Daily
- D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days
Correct Answer: A
Rationale: Lispro insulin is a rapid-acting insulin typically administered around mealtimes to manage postprandial glucose levels. Since the client is NPO, they are not eating, so administering lispro insulin could lead to hypoglycemia due to the absence of carbohydrate intake. The nurse should clarify this prescription with the PHCP to ensure safe management of the client’s blood glucose levels during the NPO period. Glargine insulin, a long-acting insulin, is appropriate for basal glucose control and does not require clarification. Vitamin B12 and clonidine are unrelated to food intake and safe for NPO status.
The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside?
- A. Overhead trapeze
- B. Abduction pillow
- C. Transfer board
- D. Continuous passive motion (CPM)
Correct Answer: A
Rationale: An overhead trapeze assists with safe repositioning and mobility post-lumbar spinal fusion, reducing strain on the surgical site. Abduction pillows are used for hip surgeries, transfer boards aid general transfers, and CPM is for joint surgeries, not spinal fusion.
The nurse is caring for a client with an indwelling urethral catheter. Which of the following actions should the nurse take? Select all that apply.
- A. Empty drainage bag when 1/2 full.
- B. Provide perineal hygiene using mild soap and hot water.
- C. Ensure tubing is clipped onto the edge of the linens.
- D. Wear sterile gloves while cleaning the urinary meatus.
- E. Clean catheter starting at meatus and moving downward while holding it securely.
Correct Answer: A,E
Rationale: Emptying the bag when half full prevents reflux, and cleaning from the meatus downward avoids contamination. Hot water is too harsh, clipping tubing risks tension, and clean gloves suffice for cleaning.