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The nurse on postpartum is preparing four clients for discharge. It would be MOST important for the nurse to refer which of the following clients for homecare?
- A. A 15-year-old who vaginally delivered a 7-lb male two days ago.
- B. An 18-year-old multipara who delivered a 9-lb female by cesarean section two days ago.
- C. A 20-year-old multipara who delivered 1 day ago and is complaining of cramping.
- D. A 22-year-old who delivered by cesarean section and is complaining of burning on urination.
Correct Answer: D
Rationale: Burning on urination suggests a urinary tract infection, requiring homecare follow-up. Options A, B, and C are routine postpartum findings.
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The nurse is caring for a child with celiac disease. The nurse's discharge teaching plan should include:
- A. Dietary instructions and a list of foods to be avoided
- B. Hand-washing instructions to prevent disease transmission
- C. Instructions to continue antibiotics for 1 week
- D. Explaining that one attack confers immunity
Correct Answer: A
Rationale: Celiac disease requires a gluten-free diet, so dietary instructions and a list of foods to avoid are essential, making A correct. Hand-washing , antibiotics , and immunity are not relevant to celiac disease management.
Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it:
- A. considers client and staff needs
- B. conserves time spent on planning
- C. frees the nurse manager to handle other priorities
- D. allows requests for special privileges
Correct Answer: A
Rationale: Decentralized staffing takes into consideration specific client needs and staff interests and abilities.
The nurse is providing home care to a 78-year-old woman who has early dementia. The client tells the nurse, 'My daughter is mean to me.' What should the nurse do initially?
- A. Report suspected elder abuse to the supervisor
- B. Report elder abuse to the authorities
- C. Ask the daughter about the mother's comment
- D. Ask the client to describe what the daughter does to be mean to her
Correct Answer: D
Rationale: The client's statement is very vague and needs to be clarified. Initially, the nurse should ask the client what the daughter does to her that is mean. Examples of behavior are important in evaluating whether the client is the victim of abuse or whether the client's dementia is affecting her perceptions. The nurse does not have enough data at this point to report the client's claim. Initially the nurse should clarify the accusation with the client. After doing that, it would be appropriate to discuss the issue with the daughter.
The nurse is caring for an older adult in his home. Which of the following factors increase the client's risk for falls? Select all that apply.
- A. The client is 78 years old.
- B. The home is a one-story home.
- C. There are several scatter rugs on the hardwood floors.
- D. The client's wife does all of the housework.
- E. There are handrails in the bathroom.
- F. There are several plants in the living room.
Correct Answer: A,C,F
Rationale: Age over 65, scatter rugs, and obstacles like plants increase fall risk. A one-story home, handrails, and the wife's housework reduce risk.
A client has just been admitted after sustaining a second-degree thermal injury to his right arm.
Which of the following nursing observations is MOST important to report to the doctor?
- A. Pain around the periphery of the injury.
- B. Gastric pH less than 6.0.
- C. Increased edema of the right arm.
- D. An elevated hematocrit.
Correct Answer: B
Rationale: Strategy: Determine how each assessment relates to burns. (1) expected findings in burn wound resolution (2) correct-decrease in gastric pH could indicate hypersecretion of hydrogen ions, predisposing factor to stress ulcer formation (3) expected findings in burn wound resolution (4) expected findings in burn wound resolution