Nokea
The nurse reinforces discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement indicates the need for additional teaching?
- A. I have to give myself shots in the belly because my spouse is afraid of needles?
- B. I have to use a walker because I cant bear any weight on this knee yet.
- C. I will call my health care provider if I get short of breath or sore or swollen below my knee
- D. The raised toilet seat makes it easier for me to get on and off the toilet by myself.
Correct Answer: A
Rationale: Self-administered anticoagulant injections require confirmation of correct technique, not spousal fear, indicating misunderstanding. Walker use , symptom reporting , and toilet aids are correct.
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The nurse is caring for an acutely ill 10 year-old client. Which of the following assessment findings would require the nurses immediate attention?
- A. Rapid bounding pulse
- B. Temperature of 101.3 degrees Fahrenheit (38.5 degrees Celsius)
- C. Profuse diaphoresis
- D. Slow, irregular respirations
Correct Answer: D
Rationale: Slow, irregular respirations. A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child. Fatigue can rapidly lead to respiratory arrest.
The nurse is reinforcing teaching on oral care and symptom management to a client with head and neck cancer who has developed mouth sores related to external radiation therapy. Which of the following instructions should the nurse include? Select all that apply.
- A. Apply a water-soluble lubricating agent to moisturize mouth tissue
- B. Avoid hot liquids and foods that are spicy or acidic
- C. Brush your teeth with a soft-bristle toothbrush
- D. Cleanse the mouth with saline after meals and at bedtime
- E. Rinse with alcohol-based antiseptic mouthwash to decrease mouth odor
Correct Answer: A,B,C,D
Rationale: Water-soluble lubricant , avoiding irritants , soft brushing , and saline rinses promote comfort. Alcohol-based mouthwash irritates sores.
The nurse is administering hygienic care to an elderly client in her home. What should the nurse wash first?
- A. Perineal area
- B. Face
- C. Upper torso
- D. Hands
Correct Answer: B
Rationale: Washing the face first during hygienic care respects client comfort and dignity, starting with a less invasive area. It also prevents cross-contamination from dirtier areas like the perineum.
The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply.
- A. Area around the insertion site feels cool to the touch
- B. Client reports mild arm discomfort after the infusion is started
- C. Edema is observed on the dependent side of the involved arm
- D. Intraoperative peripheral IV catheter was placed in the left antecubital region
- E. Serous fluid is leaking from the site despite secure connections
Correct Answer: A,C,E
Rationale: Coolness suggests infiltration or poor circulation. Edema indicates infiltration or phlebitis. Leaking serous fluid suggests dislodgement. Mild discomfort may be normal initially, and antecubital placement is acceptable unless complications arise.
After the shift report in a labor and delivery unit which of these clients would the nurse check first?
- A. A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94
- B. A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
- C. A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
- D. An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
Correct Answer: D
Rationale: This client has an actual complication. The others present with findings of potential complications. The adolescent’s symptoms suggest a serious condition, possibly pulmonary edema or fetal demise, requiring immediate assessment.