Nokea
The nurse is caring for a client with a new colostomy and notices the client is reluctant to participate in self-care. Which intervention should the nurse implement first?
- A. Teach the client's family to perform colostomy care.
- B. Refer the client to a support group.
- C. Assess the client's barriers to self-care.
- D. Provide written instructions for colostomy care.
Correct Answer: C
Rationale: Assessing the client's barriers to self-care is the first step to understand and address their reluctance, enabling tailored interventions. Teaching family, referring to a support group, or providing instructions are secondary after identifying the underlying issues. CN: Psychosocial adaptation; CL: Synthesize
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The nurse is transfusing one unit of packed red blood cells (PRBCs) to a client. The nurse initiated the transfusion at 1400. After completing the 1545 vital signs, the nurse should take which action? See the image below.
- A. Stop the transfusion
- B. Verify the blood product with another nurse
- C. Apply nasal cannula oxygen
- D. Document the findings and continue the transfusion
Correct Answer: D
Rationale: Without specific abnormal vital signs provided in the image, the nurse should document the findings and continue the transfusion if vital signs are stable, as this is standard practice after monitoring. Stopping the transfusion, verifying the product again, or applying oxygen require specific indications of a transfusion reaction or instability.
Which of the following clients is most at risk for potential hazards from the surgical experience?
- A. A 68-year-old client.
- B. A 48-year-old client.
- C. A 30-year-old client.
- D. A 13-year-old client.
Correct Answer: A
Rationale: The 68-year-old client is most at risk due to age-related declines in organ function, slower recovery, and higher likelihood of comorbidities, increasing surgical complications.
Which statement by a client with acute renal failure indicates understanding of dietary restrictions?
- A. I will avoid oranges.
- B. I can eat unlimited protein.
- C. I should drink less water.
- D. I will eat more spinach.
Correct Answer: A
Rationale: Oranges are high in potassium, which should be avoided in acute renal failure.
The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or fluid loss, requiring urgent physician attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical.
A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to:
- A. Begin total parenteral nutrition.
- B. Start a cutdown infusion.
- C. Administer tube feedings.
- D. Perform a tracheotomy.
Correct Answer: D
Rationale: Tracheotomy equipment is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy.