Nokea
The nurse is caring for a client who is postoperative day 1 following a mastectomy. The client refuses to look at the surgical site or participate in wound care teaching. Which of the following actions by the nurse is MOST appropriate?
- A. Encourage the client to express her feelings about the surgery.
- B. Insist that the client look at the surgical site.
- C. Perform the wound care without involving the client.
- D. Tell the client that she will feel better soon.
Correct Answer: A
Rationale: encouraging the client to express feelings promotes coping and addresses potential body image concerns
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The nurse is preparing a client for discharge following the removal of a cataract. The nurse should tell the client to:
- A. Take aspirin for discomfort
- B. Avoid bending over to put on his shoes
- C. Remove the eye shield before going to sleep
- D. Continue showering as usual
Correct Answer: B
Rationale: Avoiding bending over prevents increased intraocular pressure post-cataract surgery.
The client has a nitroprusside drip infusing at 0.3 mcg/kg/min. The concentration is 50 mg nitroprusside in 250 mL D5W. The client weighs 70 kg. What will the IV infusion rate be?
Correct Answer: 6.3 mL/hr
Rationale: To calculate: 0.3 mcg/kg/min × 70 kg = 21 mcg/min. Concentration is 50 mg/250 mL = 200 mcg/mL. Rate = 21 mcg/min ÷ 200 mcg/mL = 0.105 mL/min × 60 min/hr = 6.3 mL/hr.
The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peaches
- C. Cucumber salad
- D. Yeast rolls
Correct Answer: C
Rationale: Cucumber salad contains seeds and roughage, which can irritate the colon in diverticulosis and should be avoided.
Which of the following factors increase the risk of developing deep vein thrombosis (DVT)? Select all that apply.
- A. Being underweight
- B. Smoking
- C. Having surgery
- D. Taking oral contraceptives
- E. High-protein diet
- F. Immobility
Correct Answer: B,C,D,F
Rationale: DVT risk factors include smoking (B), surgery (C), oral contraceptives (D), and immobility (F). Underweight (A) and high-protein diet (E) are not significant risks.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
- A. Maternal hypoglycemia
- B. Fetal bradycardia
- C. Maternal hyperreflexia
- D. Fetal movement
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, leading to fetal bradycardia, which requires close monitoring.