Nokea
The nurse is planning to teach incisional care to a client before discharge. Which of the following instructions should be included?
- A. Do not touch your incision before your next appointment.
- B. Clean your incision three times a day with hydrogen peroxide and water.
- C. Do not be concerned about uneven lumps under the suture lines.
- D. If the staples don't come out by themselves before your next appointment, the surgeon will remove them.
Correct Answer: C
Rationale: Uneven lumps under suture lines are normal due to tissue healing and swelling. This reassurance prevents unnecessary worry. Hydrogen peroxide is not routinely recommended, and staples are typically removed by the surgeon.
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A 70-year-old male with the diagnosis of claudication has been hospitalized for an evaluation of his increasingly impaired mobility and complaints of pain. The client tells the nurse that he can no longer walk a block without having severe pain in his left calf and foot. Based on these data, which nursing diagnosis would be most appropriate for this client?
- A. Activity intolerance related to decreased blood supply and pain
- B. Self-care deficit related to increased leg pain
- C. Ineffective coping related to chronic pain
- D. Impaired skin integrity related to poor circulation
Correct Answer: A
Rationale: Activity intolerance due to decreased blood supply and pain is the most appropriate nursing diagnosis, as claudication (pain during walking) directly results from inadequate arterial blood flow, limiting mobility. The other diagnoses may apply but are less specific to the described symptoms.
Which teaching point is critical for a client with a new diagnosis of epilepsy?
- A. Avoid driving until seizures are controlled.
- B. Limit all social activities.
- C. Discontinue medications if seizures stop.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Avoiding driving until seizures are controlled is critical for safety in epilepsy management.
A client with acute renal failure has a low calcium level. The nurse should monitor for:
- A. Tetany.
- B. Hypertension.
- C. Bradycardia.
- D. Edema.
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
A nurse is treating a client who came to the emergency department after getting bit by a snake on their arm. After confirming the resuscitation equipment is at the bedside, which of the following actions by the nurse would be a priority?
- A. Contact Poison Control for guidance on an antivenom.
- B. Ensure the client's peripheral intravenous (IV) lines are patent.
- C. Apply a tourniquet above the snake bitten area on the arm.
- D. Assess for rash, fever, chills, nausea, vomiting, and joint pain.
Correct Answer: B
Rationale: Ensuring patent IV lines is the priority to enable rapid antivenom or fluid administration, critical for snakebite management. Contacting Poison Control (A) is secondary, tourniquets (C) are harmful, and symptom assessment (D) is important but not the immediate priority.
A short time after cataract surgery, the client complains of nausea. The nurse should first:
- A. Instruct the client to take a few deep breaths until the nausea subsides.
- B. Explain that this is a common feeling that will pass quickly.
- C. Tell the client to call the nurse promptly if vomiting occurs.
- D. Administer an antiemetic, as ordered.
Correct Answer: D
Rationale: Nausea after cataract surgery can indicate increased intraocular pressure or other complications. Administering an antiemetic as ordered is the priority to prevent vomiting, which could increase intraocular pressure and cause complications.