Nokea
The nurse is precepting a student nurse. The primary nurse asks the student nurse to figure the client's intake and output for the shift. Which statement by the student nurse indicates an understanding of this procedure?
- A. Wound drainage is not included in output measurement.
- B. I only need to count urinary output for my output total.
- C. I don't need to count the client's emesis since it was a small amount.
- D. I will include all IV fluids, liquids the client drank, IV flushes, and IV antibiotics in my intake total.
Correct Answer: D
Rationale: All IV fluids, oral intake, flushes, and antibiotics (D) are included in intake. Wound drainage (A), urine (B), and emesis (C) must be counted as output, regardless of amount.
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The nurse is caring for a client who just had a bone marrow biopsy. The nurse understands that which statement is the nursing priority for this client?
- A. keeping the client NPO for 2 hours
- B. avoiding contact sports for 24 hours
- C. monitoring the client for excessive bleeding
- D. applying alcohol to the site every 4 hours to prevent infection
Correct Answer: C
Rationale: Monitoring for excessive bleeding (C) is the priority post-bone marrow biopsy due to risk of hematoma. NPO (A) is unnecessary, contact sports (B) is secondary, and alcohol application (D) is not standard.
The nurse is teaching a client about peritoneal dialysis. Which complication of this treatment would the nurse instruct the client to report?
- A. bone pain
- B. confusion
- C. muscle cramps
- D. cloudy outflow
Correct Answer: D
Rationale: Cloudy outflow (D) indicates possible peritonitis, a serious complication of peritoneal dialysis requiring immediate reporting. Bone pain (A), confusion (B), and muscle cramps (C) are less specific.
The nurse is caring for a client in ICU diagnosed with rabies following a bite from an infected raccoon. The nurse understands which to be true regarding rabies? Select all that apply.
- A. The client should not be bathed, and no running water should be present within hearing of the client.
- B. Current treatment includes two doses of immunoglobulin and six doses of rabies vaccine over a period of 21 days.
- C. Nuchal rigidity, convulsions, and tonic or clonic muscle contractions can occur during the neurological phase.
- D. In the prodromal phase, the client can have irritability, extreme salivation, sore throat, fever, and hyperexcitability.
- E. During the neurological phase, the client may have aches and pains in different parts of the body, along with sensitivity to light.
- F. During the paralytic phase, the client becomes unconscious, has loss of bowel and urinary control, and has irregular or labored breathing.
Correct Answer: A,C,D,F
Rationale: Rabies causes hydrophobia, so avoid running water (A); neurological phase includes nuchal rigidity/convulsions (C); prodromal phase has irritability/salivation (D); paralytic phase involves unconsciousness/incontinence/labored breathing (F). Treatment is one immunoglobulin/four vaccines (B), and photophobia (E) is less specific.
The nurse is caring for a client who had an inguinal hernia repair. Which interventions by the nurse are appropriate for this client? Select all that apply.
- A. encouraging fluid intake
- B. relieving urinary retention
- C. applying heat to the scrotum
- D. teaching turning, coughing, and deep breathing
- E. keeping the client on bed rest for the first 12 hours after surgery
- F. teaching the client to avoid lifting more than 20 pounds until approved by the health care provider
Correct Answer: A,B,D,F
Rationale: Fluid intake (A), relieving urinary retention (B), teaching coughing/deep breathing (D), and avoiding heavy lifting (F) support recovery. Heat (C) is not standard, and bed rest (E) is not typically required.
Which nursing action is most appropriate to initially relieve pain related to a recent soft tissue injury?
- A. administer an over-the-counter (OTC) medication for pain
- B. apply heat
- C. massage the area
- D. apply ice pack
Correct Answer: D
Rationale: Ice pack (D) reduces swelling and pain in acute soft tissue injuries. OTC medication (A) is secondary, heat (B) is used later, and massage (C) may worsen swelling.