Nokea
The nurse is caring for a client with a new colostomy. Which of the following client statements indicates a need for further teaching?
- A. I will change the pouch when it is about one-third full.
- B. I will empty the pouch every evening before bed.
- C. I will avoid gas-forming foods like beans and broccoli.
- D. I will check the skin around the stoma for irritation.
Correct Answer: B
Rationale: the pouch should be emptied when one-third to one-half full, not on a fixed schedule
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The nurse is caring for a client recently diagnosed with AIDS. Which of the following interventions by the nurse would be BEST?
- A. Inspect the skin daily for signs of breakdown.
- B. Limit the number of health care personnel caring for the patient.
- C. Utilize standard precautions when administering parenteral medications.
- D. Monitor the patient's vital signs q4h.
Correct Answer: B
Rationale: implementation, decreases exposure to microorganisms
The nurse is caring for an 11-year-old girl being treated for a fractured right femur with balanced suspension traction with a Thomas ring and Pearson attachment. The physician orders 2 liters to be instilled with a dwell time of 40 minutes. The nurse measures the outflow and finds it to be 1,800 cc. During the nurse's shift, the client drinks 700 cc of fluids and voids 400 cc. The nurse should record which of the following on the client's intake and output sheet?
- A. Intake: 2,700 cc; output: 400 cc.
- B. Intake: 2,700 cc; output: 2,200 cc.
- C. Intake: 700 cc; output: 400 cc.
- D. Intake: 2,700 cc; output: 1,800 cc.
Correct Answer: B
Rationale: intake and output
On a home health visit, an elderly client states, 'This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.' Which of the following nursing responses by the nurse is BEST?
- A. Have you and your neighbors formed a neighborhood watch?
- B. It must be very difficult for you to live in this neighborhood.
- C. I see a lot of police cars, so you should be pretty safe.
- D. Tell me what has happened to make you feel that you are not safe.
Correct Answer: D
Rationale: assessing the basis for client's fears and encouraging client to talk about them is the first positive step
A client who has been abusing alcohol and other drugs for six years. The nursing diagnosis is ineffective individual coping.
Which of the following nursing actions should take priority during the working stage of their relationship?
- A. Observe the client every half-hour to determine the extent of drug-seeking behavior.
- B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.
- C. Help the client obtain a sponsor through a 12-step group in the client's local area.
- D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic.
- A. Which finding indicates a possible complication in a 23-year-old woman at 32-weeks gestation?
- B. The client’s urine Test is positive for glucose and acetone.
- C. The client has 1+ pedal edema in both feet at the end of the day.
- D. The client complains of an increase in vaginal discharge.
- E. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: Glucose and acetone in urine suggest possible gestational diabetes, which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Mild edema, increased vaginal discharge, and diaphragmatic pressure are common in late pregnancy and not necessarily indicative of complications.