Nokea
Which of the following statements is both a correctly stated nursing diagnosis and a high priority for a 65-year-old client immediately following a modified radical mastectomy and axillary dissection?
- A. Anxiety related to the mastectomy.
- B. Impaired skin integrity related to the mastectomy.
- C. Pain related to surgical incision.
- D. Self-care deficit related to dressing changes.
Correct Answer: C
Rationale: immediately after surgery, the priority is optimizing the client's comfort
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A wet-to-dry dressing is ordered for a client who has a decubitus ulcer. Which technique is appropriate?
- A. Irrigate the wound and then apply a dry dressing and cover with a wet compress.
- B. Apply a wet dressing for two hours followed by a dry dressing for two hours.
- C. Apply a wet dressing, and cover with a dry dressing.
- D. Apply a wet dressing above the wound and a dry dressing below the wound.
Correct Answer: C
Rationale: Wet-to-dry dressings involve a moist gauze applied to the wound, covered with dry gauze, to debride tissue as it dries. Other techniques are incorrect.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A.
- A. Which observation indicates appropriate care for an 18-month-old with hepatitis A?
- B. The child is placed in a private room.
- C. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- D. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
- E. The staff uses standard precautions.
Correct Answer: A
Rationale: Hepatitis A requires contact precautions for diapered or incontinent patients, including a private room to prevent transmission. Removing toys risks spreading contamination, high-fat snacks are inappropriate, and standard precautions alone are insufficient.
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
The nurse would be MOST concerned by which of the following?
- A. A CVP reading of 12 and bradycardia.
- B. Tachycardia and hypotension.
- C. Dyspnea and oliguria.
- D. Rales and tachycardia.
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload
A client with an acute attack of gout is started on colchicines (Colorys). She should be instructed to report which of the following symptoms?
- A. Diarrhea
- B. Headache
- C. Itching
- D. Fever
Correct Answer: A
Rationale: Colchicine commonly causes diarrhea, which should be reported to prevent dehydration or other complications.
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to
- A. Avoid smoking near the client
- B. Turn off oxygen during meals
- C. Adjust the liter flow to 10 as needed
- D. Remind the client to keep mouth closed
Correct Answer: A
Rationale: Avoid smoking near the client. Oxygen supports combustion, posing a fire risk if smoking occurs nearby.