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The postoperative nursing assessment of a client's ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. Which of the following clients would not have delayed fluid restrictions?
- A. The client who has undergone a bronchoscopy under local anesthesia.
- B. The client who has undergone a transurethral resection of a bladder tumor under general anesthesia.
- C. The client who has undergone a repair of carpal tunnel syndrome under local anesthesia.
- D. The client who has undergone an inguinal herniorrhaphy with spinal and intravenous conscious sedation.
Correct Answer: A,C
Rationale: Local anesthesia (bronchoscopy, carpal tunnel repair) does not affect swallowing reflexes, so fluids are not delayed. General or spinal anesthesia (B, D) impairs swallowing, requiring delayed fluid intake.
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A client has a platelet count of 31,000/µL. The nurse should instruct the client to:
- A. Pad sharp surfaces to avoid minor trauma when walking.
- B. Assess for spontaneous petechiae in the extremities.
- C. Keep the room darkened.
- D. Check for blood in the urine.
Correct Answer: A
Rationale: A platelet count of 31,000/µL indicates thrombocytopenia, increasing the risk of bleeding from minor trauma. Padding sharp surfaces helps prevent injuries that could lead to bleeding. Assessing for petechiae or checking urine are monitoring actions, not preventive instructions, and darkening the room is unrelated.
A 79-year-old female client is admitted to the hospital with a diagnosis of bacterial pneumonia. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would most like to a predisposing factor for the diagnosis of pneumonia?
- A. Age.
- B. Osteoarthritis.
- C. Vegetarian diet.
- D. Daily bathing.
Correct Answer: A
Rationale: Advanced age weakens the immune system and respiratory muscles, increasing pneumonia risk. Osteoarthritis, a vegetarian diet, and daily bathing do not directly predispose to pneumonia.
The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. To prepare the client for this procedure, the nurse should explain to the client that:
- A. Fluid and food will be withheld the morning of the examination.
- B. A tranquilizer will be given before the examination.
- C. An enema will be given before the examination.
- D. No special preparation is required for the examination.
Correct Answer: D
Rationale: A KUB radiograph requires no special preparation, as it is a non-invasive imaging test to locate renal calculi.
The son of a 78-year-old client with metastatic prostate cancer is asking the nurse about the purpose of hospice care. Which of the following statements by the nurse best describes hospice care?
- A. Hospice care uses a team approach to direct hospice activity.
- B. Clients and their families are the focus of care.
- C. The client's physician coordinates all the care.
- D. All hospice clients will die at home.
Correct Answer: B
Rationale: Hospice care focuses on the client and family, providing holistic support to enhance quality of life and comfort during the end-of-life phase.
What is the nurse's best action for a client with a suspected stroke and aphasia?
- A. Speak loudly.
- B. Use simple phrases.
- C. Write all instructions.
- D. Avoid communication.
Correct Answer: B
Rationale: Using simple phrases supports communication in stroke patients with aphasia.