Nokea
Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).
- A. Solid with red streaks.
- B. Formed but solid.
- C. Brown liquid.
- D. Tarry appearance.
- E. Multiple hard pellets.
Correct Answer: A,C,D,E
Rationale: Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up. Multiple hard pellets may indicate constipation or dehydration and should be addressed.
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A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate.Which action should the nurse take to evaluate the client for urinary retention?
- A. Review the chart for number of voids over the last 24 hours.
- B. Evaluate the client for urinary incontinence.
- C. Scan the client's bladder after voiding.
- D. Palpate the suprapubic region for distention.
Correct Answer: C
Rationale: This will help determine if there is any residual urine left in the bladder after voiding.
A client who had emergency gallbladder surgery yesterday is getting ready to be discharged.The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?
- A. Have the client demonstrate prescribed wound care.
- B. Provide written instructions in the client's native language.
- C. After each instruction, ask the client if he/she understands.
- D. Have an interpreter repeat the wound care instructions.
Correct Answer: A
Rationale: The best way to evaluate the client's understanding of self-care at home is to have the client demonstrate prescribed wound care. This allows the nurse to directly observe the client's ability to perform the necessary tasks and provide feedback and clarification as needed.
Which of the following responses would be the most therapeutic when communicating with a client who has recently had a visit from their significant other and is displaying changes in behavior?
- A. Tell me about the visit with your significant other. I can see that you are feeling lonely.
- B. I noticed that you were more insulting to the evening group after your significant other left. Why is that?
- C. Why don't you try to make some friends here so you won't feel so lonely?
- D. It sounds like your visit with your significant other was important to you. How did it go?
- E. None
- F. None
Correct Answer: D
Rationale: This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.
The healthcare provider prescribes penicillin 800,000 units intramuscularly (IM) for a patient with a streptococcal infection. The vial available is labeled Penicillin 50,000 units/mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.).
- A. 10
- B. 12
- C. 14
- D. 16
Correct Answer: D
Rationale: The healthcare provider prescribed 800,000 units of penicillin and the vial available is labeled 50,000 units/mL. To calculate the number of mL to administer, you need to divide the total number of units prescribed (800,000) by the number of units per mL (50,000). This gives you a result of 16 mL.
Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?
- A. Abdominal girth.
- B. Breath sounds.
- C. Bowel sounds.
- D. Vital signs.
Correct Answer: D
Rationale: Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client's vital signs. This includes checking the client's blood pressure, pulse rate, respiratory rate, and temperature. These measurements can provide important information about the client's overall health status and can help the nurse determine if it is safe to proceed with the procedure.