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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In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has:
- A. Enlarged, painless lymph nodes.
- B. Headache.
- C. Hyperplasia of the gums.
- D. Unintentional weight loss.
Correct Answer: A
Rationale: Early-stage CLL is often asymptomatic but may present with enlarged, painless lymph nodes due to lymphocyte accumulation. Headache, gum hyperplasia, and weight loss are not typical early findings.
In the oliguric phase of acute renal failure, the nurse should assess the client for:
- A. Pulmonary edema.
- B. Metabolic alkalosis.
- C. Hypotension.
- D. Hypokalemia.
Correct Answer: A
Rationale: Pulmonary edema is a risk in the oliguric phase due to fluid overload from reduced urine output.
Which activity should a client with an ileal conduit avoid?
- A. Swimming.
- B. Walking.
- C. Heavy lifting.
- D. Reading.
Correct Answer: C
Rationale: Heavy lifting can strain the stoma site, increasing hernia risk.
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to:
- A. Observe careful hand-washing procedures.
- B. Clean the incisional area with an antiseptic.
- C. Use prepackaged sterile dressings to cover the incision.
- D. Place soiled dressings in a waterproof bag before disposing of them.
Correct Answer: A
Rationale: Hand-washing is the most effective measure to prevent wound infection, as it reduces the risk of introducing pathogens during dressing changes.
Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of myocardial infarction?
- A. Liquids as desired.
- B. Small, easily digested meals.
- C. Three regular meals per day.
- D. Nothing by mouth.
Correct Answer: B
Rationale: Small, easily digested meals reduce the metabolic demand on the heart and prevent gastrointestinal distress, which could exacerbate myocardial oxygen demand during the acute phase of MI.