Nokea
What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
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Appropriate nursing diagnoses for a client with hypothyroidism would include which of the following?
- A. Risk for injury (corneal abrasion) related to incomplete closure of the eyelid.
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolism.
- C. A clinical evidence related to diarrhea.
- D. Activity intolerance related to fatigue associated with the disorder.
Correct Answer: D
Rationale: Hypothyroidism causes fatigue due to slowed metabolism, making activity intolerance a relevant nursing diagnosis. The other options are more associated with hyperthyroidism or unrelated conditions.
Which of the following is an environmental factor and increases the risk of cancer?
- A. Gender.
- B. Nutrition.
- C. Immunologic status.
- D. Age.
Correct Answer: B
Rationale: Nutrition is an environmental factor that influences cancer risk, as diets high in processed foods or low in fiber can increase the risk of cancers like colon cancer.
After the administration of t-PA, the assessment priority is to:
- A. Monitor the client for chest pain.
- B. Monitor for fever.
- C. Monitor the 12-lead electrocardiogram (ECG) every 4 hours.
- D. Monitor breath sounds.
Correct Answer: A
Rationale: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.
Which symptom indicates a potential complication in a client post-craniotomy?
- A. Mild headache.
- B. Clear nasal drainage.
- C. Stable blood pressure.
- D. Improved appetite.
Correct Answer: B
Rationale: Clear nasal drainage may indicate cerebrospinal fluid leakage, a serious post-craniotomy complication.
A client with terminal cancer expresses fear of dying alone. The nurse's most therapeutic response is:
- A. You won't be alone; we'll ensure someone is with you.
- B. Everyone dies alone, but it's not something to fear.
- C. Let's focus on keeping you comfortable instead.
- D. Have you considered spiritual counseling?
Correct Answer: A
Rationale: Assuring the client that someone will be present addresses their fear directly, providing emotional reassurance and support.