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The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis?
- A. Avoid the use of caffeinated beverages.
- B. Perform postural drainage every day.
- C. Take hot showers twice daily.
- D. Report a temperature of 102°F (38.9°C) or higher.
Correct Answer: C,D
Rationale: Hot showers help moisten nasal passages and promote sinus drainage, relieving symptoms of chronic sinusitis. Reporting a high fever is critical as it may indicate a worsening infection requiring medical attention. Caffeine restriction is not typically necessary. Postural drainage is more relevant for lung conditions like bronchiectasis.
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The nurse is assessing a client with a casted arm for signs of infection. Which finding is most concerning?
- A. Mild itching under the cast.
- B. Foul odor from the cast.
- C. Warmth at the cast edges.
- D. Slight swelling of fingers.
Correct Answer: B
Rationale: A foul odor from the cast suggests infection, requiring immediate evaluation.
A client has been admitted with draining foot lesions. The nurse should do which of the following? Select all that apply.
- A. Place the client in a room with negative air pressure.
- B. Admit the client to a semi-private room.
- C. Admit the client to a private room.
- D. Post a "contact isolation" sign on the door.
- E. Wear a protective gown when in the client's room.
- F. Wear latex-free gloves when providing direct care.
Correct Answer: C,D,E,F
Rationale: Draining lesions require contact precautions, including a private room, isolation signage, gowns, and gloves (latex-free to avoid allergies). Negative pressure is for airborne pathogens.
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first:
- A. Ask what medications the client is taking.
- B. Complete a history and health assessment.
- C. Identify the time of onset of the stroke.
- D. Determine if the client is scheduled for any surgical procedures.
Correct Answer: C
Rationale: The time of stroke onset is critical for t-PA administration, as it must be given within a specific window (typically 3-4.5 hours) to be effective and safe. Other assessments follow this priority.
Which finding indicates a properly functioning ileal conduit?
- A. Clear urine output.
- B. Mucus in the urine.
- C. Dry stoma site.
- D. No urine output.
Correct Answer: B
Rationale: Mucus in the urine is normal due to the intestinal segment used in the conduit.
Which of the following indicates a potential complication of diabetes mellitus?
- A. Inflamed, painful joints.
- B. Blood pressure of 160/100 mm Hg.
- C. Hemoglobin of 11 g/dL.
- D. Fasting blood glucose of 90 mg/dL.
Correct Answer: B
Rationale: Hypertension (160/100 mm Hg) is a common complication of diabetes, contributing to cardiovascular and kidney disease.