Nokea
Which of the following current clients should the nurse recommend for early discharge?
- A. A client who is receiving heparin for deep- vein thrombosis
- B. A client who has COPD and a respiratory rate of 44/min
- C. A client who has cancer and a sealed implant for radiation therapy
- D. A client who is 1 day postoperative following a vertebroplasty
Correct Answer: D
Rationale: Stable postoperative clients can be discharged safely.
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Which of the following responses should the nurse make?
- A. It is always difficult caring for someone who is terminally ill.
- B. You should consider taking a sleeping pill before bed each night.
- C. I can give you information about respite care if you are interested.
- D. I am sure you're doing a great job taking care of your mother.
Correct Answer: C
Rationale: Respite care provides temporary relief for caregivers, which can improve their well-being.
Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Palpable fontanels
- C. Natural loss of deciduous teeth
- D. Nontender, protruding abdomen
Correct Answer: D
Rationale: The correct answer is D: Nontender, protruding abdomen. This finding is expected in a child with kwashiorkor, a form of severe protein-energy malnutrition. The nontender, protruding abdomen is due to fluid accumulation in the abdomen (ascites) and the lack of muscle mass. This is a key characteristic of kwashiorkor. The other choices are incorrect because: A) Head circumference exceeding chest circumference is not a typical finding in children; B) Fontanels should be soft and flat in infants, not palpable; C) Natural loss of deciduous teeth occurs around age 6-12 years, not in infancy.
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence is the ethical principle that involves doing good and promoting the well-being of others. By sitting with the client to provide comfort after the loss of their partner, the nurse is demonstrating beneficence by showing compassion and support. Fidelity (A) relates to keeping promises and being faithful to commitments. Veracity (B) is about truthfulness and honesty. Autonomy (C) refers to respecting the client's right to make their own decisions. The other choices are not directly related to the nurse's action of providing comfort in this context.
Which of the following should the nurse use to access the port?
- A. An angiocatheter
- B. A 25-gauge needle
- C. A butterfly needle
- D. A noncoring needle
Correct Answer: D
Rationale: The correct answer is D: A noncoring needle. The nurse should use a noncoring needle to access the port because it is specifically designed for this purpose. Noncoring needles have a special tip that minimizes damage to the port septum, reducing the risk of complications such as infection or port damage. An angiocatheter (A) is not ideal for accessing a port as it is designed for venipuncture, not for accessing ports. A 25-gauge needle (B) may be too small and may not provide adequate flow. A butterfly needle (C) is not recommended for accessing ports due to its design and potential for septum damage.
Complete the following sentence by using the lists of options.The client is at highest risk for developing---- as evidenced by the client's-------
- A. endometritis
- B. mastitis
- C. perineal hematoma
- D. large for gestational age newborn
- E. group B streptococcus
- F. tracked nipple
Correct Answer: B,F
Rationale: Cracked nipples increase the risk of mastitis, especially in breastfeeding mothers.