Nokea
Which of the following statements by the client indicate an understanding of the discharge teaching? Select all that apply.
- A. I will eat small, frequent meals.
- B. I should expect my bowel movements to be pale in color.
- C. I will limit my morning coffee to no more than two cups.
- D. I will notify my provider if my urine is dark.
- E. I will eat fish for dinner at least twice per week.
Correct Answer: A,D,E
Rationale: The correct statements (A, D, E) demonstrate an understanding of discharge teaching. A shows awareness of dietary recommendations post-discharge. D indicates knowledge of abnormal urine color as a reason to notify the provider. E reflects comprehension of incorporating fish in the diet for health benefits. The incorrect choices (B, C) suggest misconceptions. B is inaccurate as pale bowel movements may indicate a liver issue. C may be harmful as coffee can interfere with medication.
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A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
- A. Act as a liaison between the facility and the media:
- B. Recommend to the provider specific acute care clients for discharge.
- C. Determine the medical needs of incoming clients through the emergency department
- D. Call in additional medical surgical unit nursing care staff.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The nurse should plan to determine the medical needs of incoming clients through the emergency department during a mass casualty event to prioritize care based on severity. This action allows for efficient allocation of resources and timely treatment for those in critical condition. Acting as a liaison with the media (A) is not a priority during such emergencies. Recommending clients for discharge (B) is inappropriate as the focus should be on incoming patients. Calling in additional staff (D) may be necessary but determining medical needs is the immediate priority.
Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate.
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: The correct answer is C: Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. This is the correct action because placing the ultrasound stethoscope above the symphysis pubis allows for optimal detection of the fetal heart rate. This location is where the fetal heart sounds are best heard due to the proximity to the fetal heart. Placing the stethoscope in this location ensures accurate assessment of the fetal heart rate.
Choice A is incorrect because placing the client in a side-lying position is not necessary for assessing the fetal heart rate with an ultrasound stethoscope. Choice B is incorrect because measuring fundal height is not relevant to assessing the fetal heart rate. Choice D is incorrect because Leopold maneuvers are used to determine fetal position and presentation, not to assess the fetal heart rate.
A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
- A. \| can continue to take St John's wort while taking this medication
- B. I know It will be& couple of weeks before the medication helps me feel better
- C. I expect this medication to raise my blood pressure
- D. I should take this medication on an empty stomach
Correct Answer: B
Rationale: Correct Answer: B: "I know It will be a couple of weeks before the medication helps me feel better"
Rationale: Amitriptyline is a tricyclic antidepressant that can take several weeks to reach its full therapeutic effect. This statement shows the client understands the delayed onset of action of the medication, managing expectations. This is crucial in ensuring the client does not become discouraged if they do not feel immediate improvement.
Incorrect Choices:
A: "I can continue to take St John's wort while taking this medication" - St John's wort can interact with amitriptyline, leading to increased side effects and reduced effectiveness.
C: "I expect this medication to raise my blood pressure" - Amitriptyline can indeed cause hypotension, not hypertension.
D: "I should take this medication on an empty stomach" - Amitriptyline should be taken with food to reduce gastrointestinal side effects and improve absorption.
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.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
- A. Initiate continuous bladder irrigation.
- B. Administer a fluid bolus
- C. Clamp the catheter tubing for 30 min.
- D. Obtain a urine specimen for culture and sensitive
Correct Answer: B
Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (D) is important, but addressing the dehydration issue takes priority.