Nokea
When giving a change of shift report, which of the following statements by the nurse is not appropriate?
- A. Randi Smith is a 38-year-old female client of Dr. Born with cholecystitis and cholelithiasis.'
- B. Mrs. Jones' pain is best relieved in the left lateral Sims position.'
- C. Mr. Levi is just contrary today and nothing is going to please him.'
- D. Mr. Emmert was able to walk around the unit twice today with no complaint of dizziness.'
Correct Answer: C
Rationale: Subjective statements like 'contrary' are inappropriate in a professional report, as they lack objectivity and clinical relevance.
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A client who had transurethral resection of the prostate complains of dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had $200 \mathrm{~mL}$ of urine output in the last 8 hours with a $1,000 \mathrm{~mL}$ intake. Which of the following interventions is a priority for the nurse at this time?
- A. Apply a condom catheter
- B. Assess for bladder distention
- C. Obtain a urine specimen for culture
- D. Teach the client Kegel exercises
Correct Answer: B
Rationale: Low urine output and dribbling post-TURP suggest possible bladder distention, which requires immediate assessment to prevent complications. Other interventions may follow based on findings.
The nurse is assessing a newborn 24 hours after birth. Which finding requires immediate reporting?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Yellowing of the skin
Correct Answer: D
Rationale: Yellowing of the skin within 24 hours suggests pathological jaundice, requiring immediate evaluation to prevent complications like kernicterus.
Which of the following is NOT an essential minimal component of the teaching that occurs prior to getting an informed consent?
- A. The purpose of the proposed treatment or procedure
- B. The expected outcomes of the proposed treatment or procedure
- C. Who will perform the treatment or procedure
- D. When the procedure or treatment will be done
Correct Answer: D
Rationale: Essential components of informed consent include the purpose , expected outcomes , and who will perform the procedure . The specific timing is not a required minimal component.
The nurse is teaching a client who is taking cyclosporine after renal transplant about medication information. The nurse should tell the client to be especially alert for which problem?
- A. Hair loss
- B. Weight loss
- C. Hypotension
- D. Signs of infection
Correct Answer: D
Rationale: Cyclosporine is an immunosuppressant medication used to prevent transplant rejection. The client should be especially alert for signs and symptoms of infection while taking this medication and report them to the primary health care provider if experienced. The client is also taught about other side/adverse effects of the medication, including hypertension, increased facial hair, tremors, gingival hyperplasia, and gastrointestinal complaints. Some weight loss may occur, but this is not as significant as the onset of an infection.
The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?
- A. Hyperactive bowel sounds.
- B. Rigid abdominal wall.
- C. Explosive diarrhea.
- D. Excessive flatulence.
Correct Answer: B
Rationale: A rigid abdominal wall is a hallmark sign of peritonitis, indicating peritoneal inflammation, often due to perforation in diverticulitis.