Nokea
While the nurse is providing preoperative teaching, the client says, 'I hate the idea of being an invalid after they cut off my leg.' The nurse's most therapeutic response should be:
- A. You'll still have one good leg to use.'
- B. Tell me more about how you're feeling.'
- C. Let's finish the preoperative teaching.'
- D. You're fortunate to have a wife who can take care of you.'
Correct Answer: B
Rationale: The therapeutic response, 'Tell me more about how you're feeling,' encourages the client to express fears and concerns, facilitating emotional support and coping. The other responses dismiss the client's feelings, prioritize teaching, or make assumptions, which are less therapeutic.
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The nurse is planning a staff development conference about measures to reduce medication errors. It would be appropriate for the nurse to state which actions may help reduce medication errors? Select all that apply.
- A. Timely medication reconciliation
- B. Delay documentation of medication administration to the end of the shift
- C. Delegate medication transcription to unlicensed assistive personnel (UAP)
- D. Limit the use of verbal orders to emergent situations
- E. Place medication dispensing systems in high-traffic areas
Correct Answer: A,D
Rationale: Timely reconciliation and limiting verbal orders reduce errors; delayed documentation, UAP transcription, and high-traffic dispensing systems increase error risk.
A client with acute renal failure is at risk for:
- A. Infection.
- B. Hypoglycemia.
- C. Hypernatremia.
- D. Bone fractures.
Correct Answer: A
Rationale: Infection risk is high due to impaired immune response and dialysis access.
A priority nursing diagnosis for an adult female who has pruritus and is continuously scratching the affected areas and demonstrates agitation and anxiety regarding the itching sensation would be:
- A. Risk for infection related to pruritus.
- B. Ineffective health maintenance related to lack of knowledge of the disease process.
- C. Unsporced skin integrity related to dehydration from the treatment medications.
- D. Social isolation related to poor self-image.
Correct Answer: A
Rationale: Scratching due to pruritus increases the risk of skin breakdown and infection, making this the priority nursing diagnosis.
Which stone type is associated with acidic urine?
- A. Calcium oxalate.
- B. Uric acid.
- C. Struvite.
- D. Cystine.
Correct Answer: B
Rationale: Uric acid stones form in acidic urine, requiring alkalinization.
The wife of a terminally ill client asks the nurse, 'Why is my husband having frequent bowel movements if he is not eating?' Which of the following responses by the nurse informs the wife about the client's condition?
- A. I know he is having frequent loose stools and it is distressing for you, but that's just the way it is.
- B. I don't know when the bowels will shut down, but they will eventually.
- C. The pain medication will eventually help to slow the process of bowel function.
- D. The intestines still produce some waste products even when a person is not eating.
Correct Answer: D
Rationale: The intestines continue to produce waste from residual secretions and cellular turnover, even with minimal intake, explaining the frequent bowel movements.