Nokea
The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours following surgery, the drainage unit is full. The nurse should do which of the following?
- A. Remove the drain from the incision.
- B. Notify the surgeon.
- C. Empty drainage.
- D. Record the amount in the unit as output on the client's chart.
Correct Answer: C
Rationale: A full portable wound suction unit (e.g., Jackson-Pratt) should be emptied to maintain suction and prevent complications. The drainage is then measured and recorded.
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A client with a family history of cancer asks the nurse what the single most important risk factor is for cancer. Which of the following risk factors should be necessary:
- A. Family history.
- B. Lifestyle choices.
- C. Age.
- D. Menopause or hormonal events.
Correct Answer: C
Rationale: Age is the most significant risk factor for cancer, as the incidence of most cancers increases with advancing age due to cumulative genetic and environmental damage.
A client is about to have a tympanoplasty, and asks the nurse what the surgical procedure involves. The nurse begins the conversation by:
- A. Assessing the client's understanding of what the physician has explained.
- B. Describing the surgical procedure.
- C. Educating the client that the procedure will close the perforation and prevent recurrent infection.
- D. Informing the client that the procedure will improve hearing.
Correct Answer: A
Rationale: Assessing the client's current understanding allows the nurse to tailor education to the client's knowledge level and address specific concerns effectively.
A client with an ileal conduit has a rash around the stoma. The nurse should:
- A. Apply a antifungal cream.
- B. Clean with soap and water.
- C. Use a larger appliance.
- D. Cover with gauze.
Correct Answer: B
Rationale: Cleaning with soap and water removes irritants, promoting rash healing.
The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which of the following?
- A. Decreased salivation.
- B. Bradycardia.
- C. Cold intolerance.
- D. Nausea.
Correct Answer: C
Rationale: Cold intolerance is a common symptom of anemia due to reduced oxygen-carrying capacity, and assessing it helps plan supportive care.
A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL and a serum potassium level of 3.5 mEq. The physician has ordered 1,000 mL 5% dextrose in water to be infused every 8 hours. Prior to implementing the physician orders, the nurse should contact the physician, explain the situation, provide background information, report the current assessment of the client, and:
- A. Suggest adding potassium to the fluids.
- B. Request an increase in the volume of intravenous fluids.
- C. Verify the order for 5% dextrose in water.
- D. Determine if the client should be placed in isolation.
Correct Answer: C
Rationale: 5% dextrose in water is inappropriate for a hyperglycemic client (325 mg/dL), as it may worsen hyperglycemia. The nurse should verify the order, likely suggesting normal saline instead.