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The nurse is providing home care to a postoperative client who has a wound infection. What is essential to include when teaching the family about infection transmission?
- A. The client should stay isolated from the rest of the family.
- B. No one who is pregnant should care for the client.
- C. The family should wash hands before and after caring for the client.
- D. The client should not be allowed to have any visitors.
Correct Answer: C
Rationale: Hand washing before and after care is critical to prevent infection transmission. Isolation, restricting pregnant caregivers, or banning visitors are not necessary unless specified.
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Several days after a client had a myocardial infarction, the physician placed him on a 2-gm sodium diet.
Which of the following selections would indicate to the nurse an understanding of the diet?
- A. Scrambled egg, orange slices, and milk.
- B. Instant oatmeal, toast, and orange juice.
- C. Poached egg, bacon, and milk.
- D. Biscuit, fruit cup, and sausage.
Correct Answer: A
Rationale: Strategy: Determine the foods that are allowed on a 2-gm sodium diet. (1) correct-all items are low in sodium; milk is allowed on a salt-restricted diet (2) instant oatmeal has sodium added (3) bacon is high in sodium (4) all baked breads are high in sodium, as is sausage
The nurse is caring for a client who is postoperative day 1 after a mastectomy. Which of the following actions should the nurse prioritize?
- A. Encourage arm exercises on the affected side.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Arm exercises prevent lymphedema and promote mobility post-mastectomy. Options B, C, and D are secondary.
A nurse is stuck in the hand by an exposed used hypodermic needle. What immediate action should the nurse take?
- A. Look up the policy on needle sticks
- B. Contact employee health services
- C. Immediately wash the hands with vigor
- D. Notify the supervisor and risk management
Correct Answer: C
Rationale: The immediate action of vigorously washing will help remove possible contamination. Then the sequence would be to notify the supervisor, look up the policy, and contact employee health services.
The nurse is teaching a client with a new diagnosis of hyperthyroidism about methimazole (Tapazole). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any fever or sore throat.
- C. Stop the medication if thyroid levels normalize.
- D. Avoid regular thyroid function Test s.
Correct Answer: B
Rationale: Fever or sore throat may indicate agranulocytosis, a serious methimazole side effect. Options A, C, and D are incorrect.
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Calcium level of 8.0 mg/dL.
- B. Temperature of 99.5°F (37.5°C).
- C. Heart rate of 100 bpm.
- D. Pain at the incision site.
Correct Answer: A
Rationale: A calcium level of 8.0 mg/dL indicates hypocalcemia, a serious complication post-thyroidectomy due to parathyroid damage, risking tetany or seizures. Options B, C, and D are expected: slight fever, tachycardia, and incision pain are common postoperatively.