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Which of the following home care instructions would be appropriate for a client with a laryngectomy?
- A. Perform mouth care every morning and evening.
- B. Provide adequate humidity in the home.
- C. Maintain a soft, bland diet.
- D. Limit physical activity to shoulder and neck exercises.
Correct Answer: B
Rationale: Adequate humidity prevents stoma crusting and maintains airway moisture. Mouth care frequency may need to be higher. Diet should be tailored to swallowing ability, not necessarily soft or bland. Physical activity should be encouraged, not limited, unless contraindicated.
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What is the priority nursing action for a client with a suspected brain tumor?
- A. Administer pain medication.
- B. Monitor neurological status.
- C. Provide emotional support.
- D. Restrict physical activity.
Correct Answer: B
Rationale: Monitoring neurological status is the priority to detect changes associated with a brain tumor.
The nurse should teach the diabetic client that which of the following is the most common symptom of hypoglycemia?
- A. Nervousness.
- B. Anorexia.
- C. Kussmaul's respirations.
- D. Bradycardia.
Correct Answer: A
Rationale: Nervousness is a common symptom of hypoglycemia due to the body's stress response to low blood glucose levels.
The nurse is reviewing a client's preoperative checklist and notes the client has not voided in the last 6 hours. The nurse should:
- A. Insert a urinary catheter.
- B. Encourage the client to void before transport.
- C. Notify the anesthesiologist.
- D. Document the finding and proceed.
Correct Answer: B
Rationale: Encouraging the client to void prevents bladder distention during surgery and reduces the need for catheterization, which carries infection risks.
The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included?
- A. Ignore the urge to void.
- B. Force fluids.
- C. Ask for the bedpan.
- D. Ring for assistance to the bathroom.
Correct Answer: D
Rationale: After cystoscopy, the client may feel an urge to void due to bladder irritation. Teaching to ring for assistance ensures safety, as ambulation may be unsteady post-procedure.
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?
- A. I need to know the client to ingest fluids.
- B. Encourage the client to drink at least 500 mL of water each hour.
- C. Request the central supply department to send supplies for straining urine.
- D. Administer an opioid analgesic as prescribed.
Correct Answer: D
Rationale: Severe pain from renal colic is the priority, requiring opioid analgesics for immediate relief to improve client comfort and cooperation.