Nokea
When assessing a client in crisis, what should the nurse prioritize?
- A. Allowing the client to work through independent problem-solving.
- B. Completing an in-depth evaluation of stressors and responses to the situation.
- C. Focusing on immediate stress reduction.
- D. Recommending ongoing therapy.
Correct Answer: C
Rationale: When a client is in crisis, the nurse's priority is to focus on immediate stress reduction. Crisis intervention aims to stabilize the client in the present moment by addressing the most pressing issues. Allowing the client to work through independent problem-solving (Choice A) may not be appropriate during a crisis as they might need immediate support. Completing an in-depth evaluation of stressors (Choice B) is important but not the immediate priority during a crisis. Recommending ongoing therapy (Choice D) may be considered later, but the immediate focus should be on reducing the client's stress and stabilizing the situation.
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The client is admitted to the unit after a cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- A. The client is at risk for evisceration.
- B. The client will require frequent dressing changes.
- C. The straps provide support for drains that are inserted in the incision.
- D. No sutures or clips are used to secure the incision.
Correct Answer: B
Rationale: Montgomery straps are used to secure dressings that require frequent changes due to the large amount of drainage usually present after a cholecystectomy. They are also beneficial for clients allergic to various types of tape. Answer A is incorrect as the client is not at higher risk of evisceration. Answer C is incorrect because Montgomery straps are not used to support drains. Answer D is incorrect as sutures or clips are typically used to secure the incision after gallbladder surgery, not Montgomery straps.
The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
- A. Increasing the infant's fluid intake
- B. Maintaining the infant's body temperature at 98.6°F
- C. Minimizing tactile stimulation
- D. Decreasing caloric intake
Correct Answer: A
Rationale: Bilirubin is excreted through the kidneys, therefore increasing fluid intake can help facilitate its elimination. Maintaining the infant's body temperature is important for overall health but does not directly assist in eliminating bilirubin, making choice B incorrect. Choices C and D are irrelevant to bilirubin elimination in this scenario and do not address the specific issue of physiologic jaundice.
The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client:
- A. To omit creams, powders, or deodorants before the exam
- B. To restrict fat intake for 1 week before the test
- C. That mammography replaces the need for self-breast exams
- D. That mammography requires a higher dose of radiation than an x-ray
Correct Answer: A
Rationale: The client undergoing a mammogram should be instructed to omit deodorants or powders beforehand because they can interfere with the imaging results. Answer A is correct as it aligns with the preparation needed before a mammogram to ensure accurate results. Answer B is incorrect because there is no requirement for fat intake restrictions before a mammogram. Answer C is incorrect because mammography does not replace the necessity of self-breast exams; both are crucial for maintaining breast health. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray. In fact, mammography uses a low dose of radiation to create images for breast examination.
In the emergency room, a nurse is responsible for triaging four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
- A. A 10-year-old with lacerations on the face
- B. A 15-year-old with sternal bruises
- C. A 34-year-old with a fractured femur
- D. A 50-year-old with a dislocated elbow
Correct Answer: B
Rationale: The 15-year-old with sternal bruises should receive priority in care as this client might be experiencing airway and oxygenation problems. Airway issues take precedence in triage. The 10-year-old with lacerations on the face, although looking bad, is not in immediate distress. The 34-year-old with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The 50-year-old with a dislocated elbow can also be seen later as dislocated elbows are not life-threatening compared to potential airway compromise.
A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?
- A. Teaching perineal wound care techniques
- B. Monitoring electrolyte levels
- C. Encouraging early ambulation
- D. Facilitating perineal wound drainage
Correct Answer: D
Rationale: The priority nursing care during the post-op period for a client who underwent an abdominal perineal resection is to facilitate perineal wound drainage. This is crucial for preventing infection of the surgical site and promoting healing. Teaching perineal wound care techniques, as in choice A, is more appropriate than ileostomy care in this scenario. While monitoring electrolyte levels is important, it is not the priority compared to ensuring proper wound drainage, making choice B less crucial. Encouraging early ambulation, as in choice C, is beneficial but not as critical as facilitating wound drainage immediately post-op.