Nokea
When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?
- A. Biofeedback
- B. Deep breathing
- C. Distraction
- D. Imagery
Correct Answer: B
Rationale: Deep breathing. Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.
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Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility?
- A. An adolescent diagnosed with sepsis 7 days ago and whose vital signs are maintained within low normal limits.
- B. A middle-aged woman known to have had an uncomplicated myocardial infarction 4 days ago
- C. An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
- D. A young adult in the second day of treatment for an overdose of acetaminophen
Correct Answer: D
Rationale: A young adult in the second day of treatment for an overdose of acetaminophen. An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst PO during that time. A strong risk of liver failure exists immediately following Tylenol overdose.
Which of these instructions should the nurse include when preparing a client for a radioactive iodine (I-131) uptake test and treatment for hyperthyroidism?
- A. Avoid taking aspirin for 3 days prior to the test.'
- B. You may eat a light breakfast on the morning of the test.'
- C. Expect to stay in the hospital for 24 hours after treatment.'
- D. In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation.'
Correct Answer: A
Rationale: In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation. The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours.
A client with a history of a splenectomy has a left upper quadrant mass and is scheduled for a splenectomy. The nurse knows that this client is most at risk for what complication?
- A. Respiratory complications
- B. Bleeding tendencies
- C. Peritonitis
- D. Intestinal obstruction
Correct Answer: B
Rationale: The spleen plays a role in filtering blood and producing immune cells. A history of splenectomy increases the risk of bleeding due to decreased platelet function and impaired immune response.
When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because
- A. normal patterns of behavior may be labeled as deviant, immoral, or insane
- B. the meaning of the client's behavior can be derived from conventional wisdom
- C. personal values will guide the interaction between persons from 2 cultures
- D. the nurse should rely on her knowledge of different developmental mental stages
Correct Answer: A
Rationale: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities.
Pressure is being exerted to the client's foot ulcer from the bottom bed guard, and the client needs to be pulled up in bed. The client weighs 130 lb. Which action by the nurse is best when no one is available to assist the nurse?
- A. Wait until sufficient help is available to pull up and reposition the client in bed
- B. Place pillows over the bed guard and elevate both of the client's legs on the pillows
- C. Place the bed in Trendelenburg position to relieve the pressure and then wait for help
- D. Use a slight Trendelenburg position, have the client lift the heels, and pull the client up in bed
Correct Answer: D
Rationale: Using a slight Trendelenburg position leverages gravity to assist in moving a lightweight client safely, while lifting the heels prevents friction injury. Waiting for help (A) delays relief, pillows (B) risk sliding, and full Trendelenburg (C) may compromise respiration.