Nokea
Which activity should a client with an ileal conduit avoid?
- A. Swimming.
- B. Walking.
- C. Heavy lifting.
- D. Reading.
Correct Answer: C
Rationale: Heavy lifting can strain the stoma site, increasing hernia risk.
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Because a client's renal stone was found to be composed of uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications?
- A. Milk, apples, tomatoes, and corn.
- B. Eggs, spinach, dried peas, and gravy.
- C. Salmon, chicken, and asparagus.
- D. Grapes, corn, cereals, and liver.
Correct Answer: A
Rationale: Milk, apples, tomatoes, and corn are low-purine and promote an alkaline-ash diet, suitable for uric acid stone prevention.
What is the priority intervention for a client with a suspected stroke?
- A. Administer aspirin.
- B. Perform a CT scan.
- C. Monitor neurological status.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: Monitoring neurological status is the priority to detect changes and guide timely stroke intervention.
A client with diabetes mellitus asks the nurse to recommend something to remove corns from his toes. The nurse should advise the client to:
- A. Apply a high-quality corn plaster to the area.
- B. Consult a physician or podiatrist about removing the corns.
- C. Apply iodine to the corns before peeling them off.
- D. Soak the feet in borax solution to peel off the corns.
Correct Answer: B
Rationale: Corns should be professionally removed by a physician or podiatrist to avoid injury or infection, especially in diabetic clients with poor healing.
When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following?
- A. The area proximal to the fracture.
- B. The actual fracture site.
- C. The area distal to the fracture.
- D. The opposite extremity for baseline comparison.
Correct Answer: C
Rationale: Assessing distal to the fracture checks for neurovascular compromise, a priority to prevent complications.
The nurse overhears a surgical team member discussing a client's procedure in the hospital cafeteria. The nurse should:
- A. Report the breach to the hospital's privacy officer.
- B. Confront the team member immediately.
- C. Document the incident in the client's chart.
- D. Ignore the conversation as it was unintentional.
Correct Answer: A
Rationale: Discussing client information in a public area violates HIPAA. Reporting to the privacy officer ensures proper handling of the confidentiality breach.