The nurse should initiate discharge planning for a client
- A. When the client or family demonstrate readiness to learn self care modalities
- B. When informed that a date for discharge has been determined
- C. Upon admission to a hospital unit or the emergency room
- D. When the client's condition is stabilized on the assigned unit
Correct Answer: C
Rationale: Upon admission to a hospital unit or the emergency room. Early discharge planning ensures continuity of care with shorter hospital stays.
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The nurse enters the room of a woman who had a vaginal hysterectomy three days ago and finds her crying. What is the best initial approach for the nurse?
- A. Ask her what seems to be troubling her
- B. Reassure her that feeling depressed is normal after this type of surgery
- C. Tell her that the nurse will ask the doctor to order hormones for her
- D. Leave the room so she can work out her feelings
Correct Answer: A
Rationale: Asking about her concerns opens therapeutic communication, addressing her emotional needs directly and empathetically.
The nurse is talking with a client who has gastroesophageal reflux disease and has been receiving long-term therapy with esomeprazole. Which of the following questions would be most important for the nurse to ask?
- A. Have you sustained any bone fractures recently?
- B. Are you experiencing an improved quality of sleep?
- C. Have you been checking your blood pressure regularly?
- D. Are you able to manage stressors in your life effectively?
Correct Answer: A
Rationale: Long-term esomeprazole use increases fracture risk due to reduced calcium absorption, making this the most critical question. Sleep, blood pressure, and stress are less directly related to esomeprazole’s side effects.
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
- A. Maintain good nutrition
- B. Stay in school
- C. Keep in contact with the child's father
- D. Get adequate sleep
Correct Answer: A
Rationale: Maintain good nutrition. Adequate nutrition, especially protein, vitamins, and iron, is critical for healthy fetal development and reducing low-birth-weight risks.
A 52-year-old woman who has thyroid cancer is treated with radioactive iodine (Iodotope). What should be included in the nursing care plan following administration of the drug? Select all that apply.
- A. Tell the client not to eat or drink anything for four hours.
- B. Tell the client not to sleep in the same room with anyone for seven days following administration.
- C. Save the client's urine in a lead container for 48 hours.
- D. Limit contact with the client to 30 minutes per person per shift on day 1.
- E. Assign client to a single room.
- F. Tell client to report weight gain and severe fatigue to health care provider.
Correct Answer: B,D,E,F
Rationale: Radioactive iodine requires isolation in a single room, limited contact (30 minutes/shift), separate sleeping for 7 days, and reporting symptoms like fatigue or weight gain (hypothyroidism). NPO or urine storage are not standard.
The nurse is caring for a client who has subclavian central venous access. Which nursing intervention is most important to prevent the spread of infection to this client?
- A. Frequent hand hygiene
- B. No artificial nails
- C. Use of chlorhexidine bath wipes
- D. Wearing personal protective equipment
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective intervention to prevent infection in central venous access, reducing pathogen transmission. No artificial nails and chlorhexidine wipes are supportive, but hand hygiene is primary. PPE is situational.
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