Nokea
The nurse is giving preoperative medication to an adult who is scheduled for surgery. The client says to the nurse that she does not want to have a transfusion during surgery because it is against her religion. The client has signed a consent form for surgery. How should the nurse respond?
- A. Explain that she has signed a consent form for surgery and that includes the use of transfusions if necessary
- B. Explain that the surgeon will probably not perform surgery if she won't have a transfusion
- C. Have the client sign an addendum to the operative permit excluding transfusions
- D. Withhold the medication and notify the physician
Correct Answer: C
Rationale: An addendum to refuse transfusions respects the client's religious beliefs, ensuring informed consent. Other responses dismiss her autonomy or delay care.
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Priorities to be considered intermediate are:
- A. the nonemergency, non-life-threatening needs of the client.
- B. those tasks that can be delegated to assistive personnel.
- C. those tasks that can be performed at the end of the shift.
- D. those task that can be performed at any time.
Correct Answer: A
Rationale: Priorities designated as intermediate by the nurse are those that are not urgent. They do not affect the client's immediate physiological status.
A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes. She sits for hours rocking back and forth and appears to be talking to someone at intervals. She does not eat or bathe or relate to others. How should the nurse approach this client upon admission?
- A. Explain the unit routines to her in detail
- B. Ask her if she has any question about the unit or what she is supposed to do
- C. Briefly explain the most essential information and then sit with her
- D. Take her by the hand and orient her to the unit
Correct Answer: C
Rationale: A withdrawn client may be overwhelmed by detailed explanations. Brief information and quiet presence build trust and reduce anxiety.
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish her supply every three months.
- B. Take one every 15 minutes if pain occurs.
- C. Leave the medication in the brown bottle.
- D. Crush the medication and take it with water.
Correct Answer: C
Rationale: The client should leave the medication in the brown bottle because light deteriorates the medication. The supply should be replenished every six months, so answer A is incorrect. One tablet should be taken every five minutes times three, so answer B is incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, so answer D is incorrect.
The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?
- A. Adhesive bandaging should remain on the lesions to prevent virus shedding
- B. Blood tests will be drawn to ensure that the virus is eradicated
- C. Condoms should be used during intercourse until the lesions are healed
- D. Gloves should be used to apply the medication to the lesions
Correct Answer: D
Rationale: Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorte
the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a
herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the
body even when active lesions are healed; however, it is still contagious, even when dormant. The infection
can be spread to other people or other parts of the body via skin-to-skin contact; therefore, gloves should be
used when applying topical antiviral or analgesic (eg, lidocaine) medications. There is no cure for genital
herpes; treatment is aimed at relieving symptoms and preventing the spread of infection
The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse?
- A. Client in a belt restraint in the semi-Fowler position
- B. Client in mitten restraints in the side-lying position
- C. Client in soft wrist restraints in the supine position
- D. Client in vest restraint in the high-Fowler position
Correct Answer: D
Rationale: A vest restraint in the high-Fowler position (D) poses a risk of strangulation or asphyxiation due to the restraint slipping upward, requiring immediate intervention. Belt restraint in semi-Fowler (A), mitten restraints in side-lying (B), and wrist restraints in supine (C) are safer positions, assuming proper application and monitoring.