Nokea
The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
- A. Call the surgeon and ask him or her to see the client to clarify the information
- B. Explain the procedure and complications to the client
- C. Check in the physician's progress notes to see if understanding has been documented
- D. Check with the client's family to see if they understand the procedure fully
Correct Answer: A
Rationale: The surgeon is responsible for ensuring informed consent, so contacting them to clarify the procedure and complications with the client is the most appropriate action.
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A client must take oral potassium supplements every day. The nurse explains to the client that the potassium supplements
- A. need to be stored in the refrigerator.
- B. should only be taken in the evening before bed.
- C. should be diluted in a glass of cold water or juice.
- D. need to be taken on an empty stomach.
Correct Answer: C
Rationale: Oral potassium supplements should be diluted in water or juice to reduce gastric irritation and improve absorption.
Which of the following characterizes peer group relationships in 8- and 9-year-olds?
- A. Activities organized around competitive games
- B. Loyalty and strong same-sex friendships
- C. Informal socialization between boys and girls
- D. Shared activities with one best friend
Correct Answer: B
Rationale: At 8-9 years, children form strong same-sex friendships with loyalty, often engaging in group activities that reinforce social bonds.
A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:
- A. The client is at risk for opportunistic diseases.
- B. The client is no longer communicable.
- C. The client's viral load is extremely low so he is relatively free of circulating virus.
- D. The client's T-cell count is extremely low.
Correct Answer: C
Rationale: A viral load of 200 copies/ml is low, indicating effective treatment and minimal circulating virus.
The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
- A. Assess the urinary output
- B. Obtain arterial blood gases
- C. Perform a dextrostick
- D. Obtain a stool culture
Correct Answer: A
Rationale: Adequate urinary output (at least 30 mL/hr) must be confirmed before adding potassium to IV fluids to prevent hyperkalemia.
A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?
- A. The pain will go away in a few days.
- B. The pain is due to peripheral nervous system interruptions. I will get you some pain medication.
- C. The pain is psychological because your foot is no longer there.
- D. The pain and itching are due to the infection you had before the surgery.
Correct Answer: B
Rationale: Phantom limb pain results from peripheral nervous system interruptions, and offering pain medication addresses the client's discomfort appropriately.