Nokea
When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which of the following information in the discharge plan? Select all that apply.
- A. Report signs of infection to health care provider.
- B. Keep the affected leg and foot on the floor when sitting in a chair.
- C. Remove anti-embolism stockings daily for laundering.
- D. None of the above
Correct Answer: A
Rationale: Reporting infection signs is critical to prevent complications. Elevating the leg when sitting and keeping stockings on reduce swelling and thrombosis risk.
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The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?
- A. Change the appliance bag.
- B. Notify the physician.
- C. Obtain a urine specimen for culture.
- D. Encourage a high fluid intake.
Correct Answer: D
Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.
A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ileal conduit:
- A. Is a temporary procedure that can be reversed later.
- B. Diverts urine into the sigmoid colon, where it is expelled through the rectum.
- C. Conveys urine from the ureters to a stoma opening on the abdomen.
- D. Creates an opening in the bladder that allows urine to drain into an external pouch.
Correct Answer: C
Rationale: An ileal conduit diverts urine from the ureters to an abdominal stoma, where it is collected in an external pouch, a permanent procedure for bladder cancer management.
Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will:
- A. Maintain a fluid intake of 800 mL every 24 hours.
- B. Experience chills only once a day.
- C. Cough productively without chest discomfort.
- D. Experience less nasal obstruction and discharge.
Correct Answer: D
Rationale: An expected outcome for recovery from an upper respiratory tract infection is reduced nasal obstruction and discharge, indicating resolution of inflammation and infection. A fluid intake of 800 mL is too low; 1,500–2,000 mL is more appropriate. Chills are not a typical measure of recovery. Productive coughing without discomfort may occur but is less specific than reduced nasal symptoms.
The unliscensed assistive personnel (UAP) reports to the registered nurse that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vital signs in the chart obtained by the UAP. The nurse should:
- A. Maintain complete bed rest.
- B. Check the urine output.
- C. Ask the UAP to change the linens.
- D. Administer a beta blocker
Correct Answer: B
Rationale: A client with pneumonia experiencing diaphoresis is at risk for dehydration. The fluid status, intake, and output should be monitored closely. The client is febrile, causing an increase in heart rate. Fluid volume defi cit may also increase the heart rate. A beta blocker is not indicated since the underlying cause of the tachycardia can be treated with acetaminophen (Tylenol) and fl uid volume. Bed rest limits lung expansion and sitting up and deep breathing should be encouraged in a client with pneumonia. The blood pressure is stable enough to allow the client to get out of bed to the chair, with assistance to ensure safety
The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug?
- A. The drug's execution peaks in 2 hours.
- B. Maximum dosage is not achieved until 3 to 4 days after starting the medication.
- C. Effects of the drug continue for 4 to 5 days after discontinuing the medication.
- D. Protamine sulfate is the antidote for warfarin.
- E. I should have my blood levels tested periodically.
Correct Answer: B,C,E
Rationale: Warfarin's maximum effect takes 3-4 days (B), its effects persist 4-5 days after stopping (C), and periodic blood tests (e.g., INR) are required (E). Peak action is not 2 hours, and protamine sulfate is the antidote for heparin, not warfarin.