Nokea
The nurse on a physical rehabilitation unit is assigned a 63-year-old male client post-amputation of his left lower limb above the knee two weeks prior. The client has a history of peripheral vascular disease due to diabetes mellitus. Which statement by the client indicates a need for further teaching?
- A. I had my leg removed because of diabetes.
- B. My exercises are going well.
- C. My left leg hurts after I wrap my stump.
- D. I use canes to walk to the bathroom.
Correct Answer: C
Rationale: Pain after wrapping the stump may indicate improper wrapping or complications, requiring further assessment and education.
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The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
- A. That cannot be assessed
- B. That is in situ
- C. With increasing lymph node involvement
- D. With distant metastasis
Correct Answer: B
Rationale: Tis indicates a tumor in situ, meaning it is noninvasive and confined to its original site, requiring specific care planning.
Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
- A. Change the dressings once per shift
- B. Moisten the dressing with sterile water
- C. Change the dressings only when they become soiled
- D. Moisten the dressing with normal saline
Correct Answer: B
Rationale: Acticoat dressings require moistening with sterile water to activate the silver release, which provides antimicrobial effects for burn wounds.
Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for:
- A. Methergine
- B. Stadol
- C. Magnesium sulfate
- D. Phenergan
Correct Answer: A
Rationale: Methergine promotes uterine contractions to control postpartum hemorrhage, indicated for heavy lochia with clots.
An elderly client's wife tells a nurse she is concerned because her husband insists on talking about past events. The nurse assesses the client and finds him alert, oriented, and responsive to questions. Which statement should the nurse make to the client's wife?
- A. Your husband is choosing to live in a happier time in his life.
- B. Redirect your husband to speak about current events when he begins regressing into the past.
- C. If he were my husband, I would call our minister to speak to him.
- D. Your husband is reflecting on his life. This is normal at his age.
Correct Answer: D
Rationale: Reflecting on past events is a normal part of aging, especially in older adults, and this response reassures the wife while providing accurate information.
In caring for a critically ill client with a nasogastric tube (NGT) for enteral feeding, which action by the nurse demonstrates competency in NGT care? Select all that apply.
- A. The nurse checks gastric residual every 4 hours for continuous feedings.
- B. The nurse maintains the client in a low Fowler's position during feeding.
- C. The nurse checks gastric residual before each bolus or intermittent feeding.
- D. The tubing is changed every 48 hours or when the bag appears visibly soiled.
- E. The nurse returns the residual to the stomach unless the volume is greater than 250 mL.
Correct Answer: A, C, E
Rationale: Checking residuals for continuous and bolus feedings and returning residuals (unless >250 mL) are standard. Low Fowler’s increases aspiration risk, and tubing change frequency varies by policy.