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Which activity would be appropriate to delegate to unlicensed personnel for a client diagnosed with a myocardial infarction who is stable?
- A. Evaluate the lung sounds.
- B. Help the client identify risk factors for CAD.
- C. Provide teaching on a 2 g sodium diet.
- D. Record the intake and output.
Correct Answer: D
Rationale: Recording intake and output is within the scope of unlicensed personnel, as it involves observation and documentation, not assessment or teaching.
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For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
- A. Speaking loudly.
- B. Using a picture board.
- C. Writing directions so client can read them.
- D. Speaking in short sentences.
Correct Answer: B
Rationale: A picture board is most helpful for expressive aphasia, allowing the client to point to images to communicate needs. Speaking loudly, writing directions, or short sentences are less effective for clients unable to verbalize.
A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse incorporate into the discharge instructions? Select all that apply.
- A. A limit of least 3,000 mL of fluid each day.
- B. Minimize daily activities.
- C. Keep urine alkaline to prevent urinary tract infections.
- D. Avoid odor-producing foods, such as onions, fish, eggs, and cheese.
- E. Wear snug clothing over the stoma to encourage urine flow into the drainage bag.
Correct Answer: A,D
Rationale: An adequate fluid intake aids in the prevention of urinary calculi and infection. Odor-producing foods should be avoided as they can affect the client's lifestyle and relationships. Minimizing activities can lead to urinary stasis, promoting infection. Alkaline urine may increase infection risk, and snug clothing is not recommended as it may irritate the stoma.
In which of the following clients is an autotransfusion contraindicated?
- A. The client who has cancer.
- B. The client who is in danger of cardiac arrest.
- C. The client with a contaminated wound.
- D. The client with a ruptured bowel.
Correct Answer: A,C,D
Rationale: Autotransfusion is contraindicated in cancer (risk of spreading malignant cells), contaminated wounds, or ruptured bowel (risk of infection or bacterial spread). It may be used cautiously in cardiac arrest if no other contraindications exist.
College freshman are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on:
- A. Water sanitation.
- B. Single dormitory rooms.
- C. Vaccine for hepatitis B.
- D. Safe sexual practices.
Correct Answer: D
Rationale: Hepatitis B is transmitted via blood and body fluids, so safe sexual practices (D) are critical for prevention. Water sanitation (A) is more relevant for hepatitis A. Single rooms (B) are unnecessary. The vaccine (C) is preventive but not the focus of behavioral instruction.