Nokea
The nurse prepares a client with a peripheral intravenous (IV) site for home IV therapy for discharge. Which should the nurse teach the client to help prevent phlebitis and infiltration?
- A. Massage the IV site daily.
- B. Immobilize the extremity.
- C. Stabilize the cannula with tape.
- D. Cleanse the site daily with alcohol.
Correct Answer: C
Rationale: Stabilizing the cannula with tape prevents movement, reducing the risk of phlebitis and infiltration. Massaging the site can cause tissue damage, immobilizing the extremity is unnecessary, and alcohol cleansing causes skin drying and discomfort.
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A client tells the nurse that he gets dizzy and lightheaded with each use of the incentive spirometer. The nurse asks the client to demonstrate the use of the device. Which action should the nurse expect to be a contributing factor in this client's symptoms?
- A. Inhaling too slowly
- B. Exhaling too slowly
- C. Not resting adequately between breaths
- D. Not forming a tight seal around the mouthpiece
Correct Answer: C
Rationale: Hyperventilation, caused by not resting adequately between breaths, is the most common cause of respiratory alkalosis, leading to lightheadedness and dizziness during incentive spirometer use. Inhaling or exhaling too slowly or not forming a tight seal may reduce effectiveness but does not cause these symptoms.
The school nurse provides teaching about the hazards of smoking to a group of high school students. Which comment by a student indicates the need for additional teaching?
- A. Chewing tobacco is much safer than is smoking tobacco.
- B. Smoking during pregnancy increases the risk of stillbirth.
- C. My health is at risk when my family smokes in the house.
- D. Inhaling smoke from other people is a public health issue.
Correct Answer: A
Rationale: All forms of tobacco use, including chewing tobacco, are health hazards. Smoking during pregnancy, smoking in a household, and second-hand smoke all present health hazards of tobacco use. Chewing tobacco is not safer than smoking and can lead to oral cancer and other health issues.
The nurse has given the client with a nephrostomy tube instructions to follow after hospital discharge to prevent complications. The nurse determines that the client understands the instructions if the client verbalizes the need to drink how many glasses of water per day?
- A. 1 to 3
- B. 6 to 8
- C. 10 to 12
- D. 14 to 16
Correct Answer: B
Rationale: The client with a nephrostomy tube needs to have adequate fluid intake to dilute urinary particles that could cause calculus and provide good mechanical flushing of the kidney and the tube. The nurse encourages the client to take in 2000mL of fluid per day, which is roughly equivalent to 6 to 8 glasses of water. One to three glasses of water is an inadequate amount. Amounts over 10 glasses of water could distend the renal pelvis.
A client has been experiencing muscle weakness for a period of several months. The health care provider suspects polymyositis, and the client asks the nurse about the disorder. The nurse explains to the client that which occurs in this disorder?
- A. Increased fibers and tissue
- B. Muscle fibers are inflamed.
- C. Muscle fibers are thickened.
- D. A decrease in elastic tissue
Correct Answer: B
Rationale: Polymyositis is a diffuse inflammatory disorder of skeletal (striated) muscle that is characterized by symmetrical weakness and atrophy. Increased fibrous tissue is seen in clients diagnosed with ankylosis. Thickened muscle fibers describe the opposite of what is noted with this disorder. Decreased elastic tissue, if it occurred in the aorta, would be noted in a client with Marfan's syndrome.
The nurse is demonstrating colostomy care to a client with a newly created colostomy. The nurse demonstrates the correct cutting of the appliance by making the circle how much larger than the client's stoma?
- A. 1/8 inch
- B. 1/4 inch
- C. 1/2 inch
- D. 1 inch
Correct Answer: A
Rationale: The size of the opening for the appliance is generally cut 1/8 inch larger than the size of the client's stoma. This minimizes the amount of exposed skin but does not put pressure on the stoma. The larger sizes leave too much skin area exposed for irritation by gastrointestinal contents.