Nokea
The nurse is teaching the client and family how to manage possible nausea and vomiting at home. The nurse should include information about:
- A. Eating frequent, small meals throughout the day.
- B. Eating three normal meals a day.
- C. Eating only cold foods with no odor.
- D. Limiting the amount of fluid intake.
Correct Answer: A
Rationale: Eating frequent, small meals helps prevent nausea by avoiding an empty or overly full stomach, which can trigger vomiting during chemotherapy.
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A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ileal conduit:
- A. Is a temporary procedure that can be reversed later.
- B. Diverts urine into the sigmoid colon, where it is expelled through the rectum.
- C. Conveys urine from the ureters to a stoma opening on the abdomen.
- D. Creates an opening in the bladder that allows urine to drain into an external pouch.
Correct Answer: C
Rationale: An ileal conduit diverts urine from the ureters to an abdominal stoma, where it is collected in an external pouch, a permanent procedure for bladder cancer management.
There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.
- A. Cut around blood stains to remove clothing.
- B. Place each item of clothing in a separate paper bag.
- C. Allow clothing to dry.
- D. Refrain from documenting client statements.
- E. Place bullets in a sterile container.
Correct Answer: B
Rationale: To preserve forensic evidence, clothing should be placed in separate paper bags to prevent cross-contamination. Cutting around blood stains or placing bullets in sterile containers may damage evidence, and documentation of statements is necessary for legal purposes.
Which of the following signs and symptoms would probably indicate that the client with Addison's disease is receiving too much glucocorticoid replacement?
- A. Anorexia.
- B. Dizziness.
- C. Rapid weight gain.
- D. Poor skin turgor.
Correct Answer: C
Rationale: Rapid weight gain indicates fluid retention, a sign of excessive glucocorticoid replacement.
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported?
- A. Give the report face-to-face with both nurses in a quiet room.
- B. Audiotape the report for future reference and documentation.
- C. Use a printed checklist with information individualized for the client.
- D. Document essential transfer information in the client's electronic health record.
Correct Answer: C
Rationale: A printed checklist individualized for the client ensures all essential information is systematically communicated, reducing errors during handoff.
The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which of the following are expected normal findings? Select all that apply.
- A. Reduced edema of the left knee.
- B. Skin warm to touch.
- C. Capillary refill response.
- D. A 55-year-old response.
- E. Pain absent.
- F. Pulse on left leg weaker than right leg.
Correct Answer: A,B,C
Rationale: Reduced edema, warm skin, and normal capillary refill are expected post-surgery. Pain is typically present, and pulses should be equal.