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The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included?
- A. Ignore the urge to void.
- B. Force fluids.
- C. Ask for the bedpan.
- D. Ring for assistance to the bathroom.
Correct Answer: D
Rationale: After cystoscopy, the client may feel an urge to void due to bladder irritation. Teaching to ring for assistance ensures safety, as ambulation may be unsteady post-procedure.
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The nurse's discharge teaching plan for the client with heart failure should stress the importance of which of the following?
- A. Maintaining a high-fiber diet.
- B. Walking 2 miles every day.
- C. Obtaining daily weights at the same time each day.
- D. Remaining sedentary for most of the day.
Correct Answer: C
Rationale: Daily weights at the same time detect fluid retention early, a key strategy to prevent heart failure exacerbations.
The nurse reviews a client's medical history and identifies a diagnosis of presbycusis. The nurse should integrate which intervention in the care plan?
- A. Have educational materials in large print
- B. Provide an eye patch to the affected eye
- C. Request food be seasoned with herbs
- D. Move closer to the better-hearing ear
Correct Answer: D
Rationale: Presbycusis is age-related hearing loss, so moving closer to the better-hearing ear facilitates communication. Large print materials and eye patches address vision issues, and herb-seasoned food is unrelated.
The nurse should remind the unlicensed personnel that which of the following is the most important goal in the care of the neutropenic client in isolation?
- A. Listening to the client's feelings of concern.
- B. Completing the client's care in a nonhurried manner.
- C. Performing all of the client's care at one time.
- D. Instructing the client to dispose of tissue after blowing the nose.
Correct Answer: C
Rationale: Performing all care at one time minimizes disruptions and reduces the risk of introducing pathogens to a neutropenic client in isolation. Emotional support, nonhurried care, and tissue disposal are important but secondary to infection prevention.
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which of the following would be an expected outcome for a client with an ileal conduit?
- A. The client verbalizes the understanding that his physical activity must be curtailed.
- B. The client states that he will place an aspirin in the drainage pouch to help control odor.
- C. The client demonstrates how to catheterize the stoma.
- D. The client states that he will empty the drainage pouch frequently throughout the day.
Correct Answer: D
Rationale: Frequent pouch emptying is an expected outcome, preventing complications like leakage or infection. Aspirin is unsafe, and stoma catheterization is not typical.
The nurse is caring for a client in skeletal traction for a femoral fracture. Which assessment should be prioritized?
- A. Skin integrity at pin sites.
- B. Room temperature control.
- C. Frequency of bowel movements.
- D. Client's emotional status.
Correct Answer: A
Rationale: Pin site infections are a common complication in skeletal traction, requiring prioritized assessment.