Nokea
The nurse is preparing to discharge a client after an abdominal cholecystectomy for treatment of cholelithiasis. The client will go home with a T-tube in place. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching?
- A. It will be great to finally get home, take a shower, and wash my hair.
- B. If the amount of drainage increases over the next several days, I should call my physician.
- C. I can resume swimming laps three times a week at my health club.
- D. I will check the skin around the tube once a day to see how it is doing.
Correct Answer: C
Rationale: Swimming submerges the T-tube, risking infection, indicating a need for further teaching. Options A, B, and D are correct: showering is allowed, increased drainage requires reporting, and daily skin checks prevent complications.
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The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST?
- A. A two-day-old infant, lying quietly alert, heart rate of 185 bpm.
- B. A one-day-old infant, crying, and the anterior fontanel is bulging.
- C. A 12-hour-old infant, held by the mother, respirations 45 and irregular.
- D. A five-hour-old infant, sleeping, hands and feet are blue bilaterally.
Correct Answer: A
Rationale: A heart rate of 185 bpm indicates tachycardia (normal 120–160 bpm), suggesting distress or dehydration, requiring immediate assessment. Options B, C, and D are less urgent or normal.
A woman who was recently widowed says to the nurse, 'I just can't believe he's gone. Sometimes I even think I see him standing there.' What does this comment indicate about the client?
- A. She is in an early stage of normal grief.
- B. She may be hallucinating.
- C. She may be having illusions.
- D. She may be in a severe depression.
Correct Answer: A
Rationale: Disbelief and transient perceptions of the deceased are normal in early grief. Hallucinations, illusions, or depression require more persistent or severe symptoms.
A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to
- A. promote verbal and nonverbal communication with both the client and the interpreter
- B. speak only a few sentences at a time and then pause for a few moments
- C. plan that the encounter will take more time than if the client spoke English
- D. ask the client to speak slowly and to look at the person spoken to
Correct Answer: A
Rationale: The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues.
Which of the following should the nurse implement to prepare a client for a kidney, ureter, bladder (KUB) radiograph test?
- A. Client must be NPO before the examination
- B. Enema to be administered prior to the examination
- C. Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
- D. No special orders are necessary for this examination
Correct Answer: D
Rationale: No special orders are necessary for this examination. No special preparation is necessary for this examination.
An adult male had a myocardial infarction six weeks ago. He asks the nurse if it is safe for him to have sex. What should the nurse include when replying?
- A. Taking nitroglycerin before sexual activity is often helpful.
- B. Taking drugs for erectile dysfunction in addition to nitroglycerin is advised.
- C. The client should rest for several hours before engaging in sexual activity.
- D. Sexual activity should be avoided for six months after a heart attack.
Correct Answer: A
Rationale: Nitroglycerin before sexual activity can prevent angina, and sexual activity is generally safe 6 weeks post-MI if the patient is stable.