Nokea
The nurse is giving medication instructions to a client who is receiving furosemide. Which client statement indicates a need for further teaching?
- A. I need to change positions slowly.
- B. I need to be careful to not get overheated in warm weather.
- C. I need to talk to my primary health care provider about the use of alcohol.
- D. I need to avoid the use of salt substitutes because they contain potassium.
Correct Answer: D
Rationale: Furosemide is a potassium-losing diuretic, so there is no need to avoid high-potassium products, such as a salt substitute. Orthostatic hypotension is a risk, and the client must use caution when changing positions and with exposure to warm weather. The client needs to discuss the use of alcohol with the primary health care provider.
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The nurse has provided instructions to a client who is receiving external radiation therapy. Which statement by the client indicates a need for further teaching regarding self-care related to the radiation therapy?
- A. I need to eat a high-protein diet.
- B. I need to avoid exposure to sunlight.
- C. I need to wash my skin with a mild soap and pat it dry.
- D. I need to apply pressure on the irritated area to prevent bleeding.
Correct Answer: D
Rationale: The client receiving external radiation therapy should avoid pressure on the irritated area and wear loose-fitting clothing. Specific health care provider instructions would be necessary to obtain if an alteration in skin integrity occurred as a result of the radiation therapy. The remaining options are accurate measures regarding radiation therapy.
The nurse is educating the client on how to save lives and prevent burn injuries, in the event of a fire in the home. Which statement by the client indicates that the teaching has been effective?
- A. I should lace escape ladders in the bedrooms.
- B. I should install a whole-house sprinkler system.
- C. I should keep fresh batteries in smoke detectors.
- D. I should mount fire extinguishers in several areas.
Correct Answer: C
Rationale: The early detection of smoke using a smoke detector and immediate evacuation from the house have significant and positive effects on mortality rates. This is because the smoke alarm activates before the appearance of open flames, which gives people in the house a chance to evacuate without burn injuries. Option 1 helps people in the house escape from second-story rooms safely, but it does not alert the people to the fire before flames are evident, thus exposing them to the risk of burn injury. Installing a sprinkler system is very expensive, and this is usually not done in private residences. Fire extinguishers are a good idea to have in the kitchen and other areas for small fires, but they are not designed to extinguish large fires.
The student nurse is listening to an orthopedic lecture on preoperative education and knee surgeries. Which statement by the student nurse indicates that the teaching has been effective?
- A. Crutch walking instructions should be scheduled before surgery.
- B. Crutch walking instructions should be given on the first postoperative day.
- C. Crutch walking instructions should be scheduled on the second postoperative day.
- D. Crutch walking instructions should be scheduled at the time of discharge after surgery.
Correct Answer: A
Rationale: It is best to assess crutch-walking ability and instruct the client with regard to the use of the crutches before surgery because this task can be difficult to learn when the client is in pain and not used to the imbalance that may occur after surgery. None of the remaining options are appropriate times to teach a client about crutch walking.
During a health assessment the nurse provides instructions to a client regarding the testicular self-examination (TSE). Which statement by the client indicates that the client needs further teaching regarding TSE?
- A. I know to report any small lumps.
- B. I should examine myself every 2 months.
- C. I should examine myself after I take a warm shower.
- D. I know it's normal to feel something that is cord-like in the back.
Correct Answer: B
Rationale: TSE should be performed every month. Small lumps or abnormalities should be reported. The spermatic cord finding is normal. After a warm bath or shower, the scrotum is relaxed, which makes it easier to perform TSE.
The nurse is providing discharge teaching for a client diagnosed and treated for tuberculosis (TB). Which statement by the client indicates that teaching has been effective? Select all that apply.
- A. All used dishes should be sterilized.
- B. My close contacts should be tested for TB.
- C. Soiled tissues should be disposed of properly.
- D. House isolation is required for at least 8 months.
- E. The mouth should always be covered when coughing.
Correct Answer: B,C,E
Rationale: Tuberculosis is a communicable disease, and the nurse must teach the client measures to prevent its spread. Any close contacts with the client must be tested and treated if the results of the screening test are positive. Because it is an airborne disease, the client must properly dispose of used tissues and needs to cover the mouth when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the house. Once the client is treated and results of three sputum cultures are negative, the client will not spread the infection.