Nokea
Which statement by a client with a new ileal conduit indicates a need for further teaching?
- A. I will empty the pouch when it is one-third full.
- B. I can use vinegar to clean my appliance.
- C. I should drink 2,000 mL of fluid daily.
- D. I will wear tight clothing to hide the pouch.
Correct Answer: D
Rationale: Tight clothing can irritate the stoma and impair appliance function, indicating a misunderstanding of proper care.
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Which activity would be appropriate to delegate to unlicensed personnel for a client diagnosed with a myocardial infarction who is stable?
- A. Evaluate the lung sounds.
- B. Help the client identify risk factors for CAD.
- C. Provide teaching on a 2 g sodium diet.
- D. Record the intake and output.
Correct Answer: D
Rationale: Recording intake and output is within the scope of unlicensed personnel, as it involves observation and documentation, not assessment or teaching.
The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the client's postoperative status?
- A. Radial pulse
- B. Pedal pulse
- C. Brachial pulse
- D. Popliteal pulse
Correct Answer: B
Rationale: Assessing the pedal pulse post-femoral-popliteal bypass is most accurate for evaluating graft patency and distal perfusion. A palpable or Doppler-detected pedal pulse indicates successful restoration of blood flow to the lower extremity. Other pulses (radial, brachial, popliteal) are less specific to the surgical site.
Thirty people are injured in a train derailment. Ineffective and the transported to the hospital first?
- A. A 20-year-old who is unresponsive and has a high injury to his spinal cord.
- B. An 80-year-old who has a compound fracture of the arm.
- C. A 10-year-old with a laceration on his leg.
- D. A 25-year-old with a sucking chest wound.
Correct Answer: D
Rationale: A sucking chest wound is a life-threatening condition that can impair breathing and requires immediate intervention, prioritizing this patient for transport over others with less urgent injuries.
A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
In which of the following clients is an autotransfusion contraindicated?
- A. The client who has cancer.
- B. The client who is in danger of cardiac arrest.
- C. The client with a contaminated wound.
- D. The client with a ruptured bowel.
Correct Answer: A,C,D
Rationale: Autotransfusion is contraindicated in cancer (risk of spreading malignant cells), contaminated wounds, or ruptured bowel (risk of infection or bacterial spread). It may be used cautiously in cardiac arrest if no other contraindications exist.