Nokea
The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in this client's discharge teaching plan?
- A. Take prescribed cortisone accurately.
- B. Use a walker when weakness occurs.
- C. Avoid extreme environmental temperatures.
- D. Increase daily intake of sodium in diet.
Correct Answer: A
Rationale: Accurate cortisone administration is vital to manage Addison's disease and prevent adrenal crisis.
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The nurse is educating a client, who was admitted with a blood glucose level of 580 mg/dL, on how to prevent complications related to diabetes mellitus. Which statement made by the client indicates they have understood the information?
- A. Apply lotion to the entire foot to prevent skin cracks.
- B. Use salt, herbs, and spices to enhance the flavor of foods.
- C. Include no more than 1-2 alcoholic beverages in the diet per day.
- D. Obtain an A1C blood test every year to monitor glucose control.
Correct Answer: B
Rationale: Using salt, herbs, and spices supports a healthy diet, aiding diabetes management and reducing complication risks.
The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has a fracture of the femur and is bleeding at the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin subcutaneously daily. Which is the priority nursing action?
- A. Notify the healthcare provider of the client's medication history.
- B. Ensure that the potential for bleeding is explained to the client.
- C. Have the client sign the surgical and transfusion permits.
- D. Observe the heparin injection sites for signs of bruising.
Correct Answer: A
Rationale: Notifying the healthcare provider of the client's heparin use is critical as it increases bleeding risk, requiring potential adjustments to the surgical plan or anticoagulation management.
A client arrives at the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Decrease the flow rate.
- B. Irrigate the catheter manually.
- C. Discontinue infusing solution.
- D. Monitor catheter drainage.
Correct Answer: B
Rationale: Manual irrigation dislodges blood clots, ensuring catheter patency and preventing urinary obstruction.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. White blood cell count.
- B. Platelet count.
- C. Red blood cell count.
- D. Hemoglobin levels.
Correct Answer: B
Rationale: Platelet count is critical as low levels cause petechiae and ecchymosis due to bleeding tendencies.
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
- A. Lower back pain and hypotension.
- B. Delayed painful rash with urticaria.
- C. Acute rhinitis and nasal stuffiness.
- D. Arthritic joint changes and chronic pain.
Correct Answer: A
Rationale: Lower back pain and hypotension are indicative of an acute ABO incompatibility reaction, which can lead to severe complications like hemolysis or shock, requiring immediate reporting and intervention.