Nokea
The nurse is teaching a client with a total knee replacement about incision care. Which statement by the client indicates a need for further teaching?
- A. I'll keep the incision clean and dry.'
- B. I'll report redness or drainage.'
- C. I'll change the dressing weekly.'
- D. I'll avoid soaking the incision.'
Correct Answer: C
Rationale: Changing the dressing weekly is too infrequent; daily or as-needed changes are required to monitor for infection.
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The client with tuberculosis is to be discharged home with community health nursing follow-up. Of the following nursing interventions, which should have the highest priority?
- A. Offering the client emotional support.
- B. Teaching the client about the disease and its treatment.
- C. Coordinating various agency services.
- D. Assessing the client's environment for sanitation.
Correct Answer: B
Rationale: Teaching about the disease and treatment is the priority to ensure adherence to the lengthy regimen, preventing relapse or resistance. Emotional support, agency coordination, and sanitation are important but secondary.
The nurse measures the amount of bile drainage from a T-tube and records it by which one of the following method:
- A. Adding it to the client's urine output.
- B. Charting it separately on the output record.
- C. Adding it to the amount of wound drainage.
- D. Subtracting it from the total intake for each day.
Correct Answer: B
Rationale: T-tube drainage is bile output and should be recorded separately on the output record (option B) to accurately track fluid loss. Adding it to urine output (A) or wound drainage (C) is incorrect as it represents a distinct type of output. Subtracting it from intake (D) is not a standard practice.
When teaching a client to deep breathe effectively after a lobectomy, the nurse should instruct the client to do which of the following?
- A. Occurnt the abdominal muscles, take a slow deep breath through the nose and hold it for 3 to 5 seconds, then exhale.
- B. Contract the abdominal muscles, take a deep breath through the mouth, and exhale slowly as if trying to blow out a candle.
- C. Relax the abdominal muscles, take a slow deep breath through the nose, and hold it for 3 to 5 seconds.
- D. Relax the abdominal muscles, take a deep breath through the mouth, and exhale slowly over 10 seconds.
Correct Answer: C
Rationale: Effective deep breathing post-lobectomy involves relaxing abdominal muscles, taking a slow nasal breath, holding it 3–5 seconds, and exhaling to expand lungs. Contracting muscles or mouth breathing is less effective.
When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which of the following physiologic functions?
- A. Bleeding tendencies.
- B. Intake and output.
- C. Peripheral sensation.
- D. Bowel function.
Correct Answer: A
Rationale: Aplastic anemia causes pancytopenia, including thrombocytopenia, which increases the risk of bleeding. The nurse should assess for bleeding tendencies, such as petechiae, bruising, or mucosal bleeding. Intake/output, sensation, and bowel function are not primarily affected.
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.