Nokea
You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about?
- A. A prolapsed stoma
- B. A vitamin B12 deficiency
- C. Nocturnal enuresis
- D. GI stone formation
Correct Answer: A
Rationale: A prolapsed stoma is a potential complication of a colostomy, and clients should be educated to recognize and report it.
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The nurse is caring for a client post-myocardial infarction. Which activity should the nurse encourage to promote recovery?
- A. Bed rest for 48 hours
- B. Light ambulation as tolerated
- C. Heavy lifting after 24 hours
- D. High-intensity exercise
Correct Answer: B
Rationale: Light ambulation as tolerated promotes circulation and prevents complications like deep vein thrombosis, while avoiding overexertion post-myocardial infarction.
You are caring for a client at the end of life. The client tells you that they are grateful for having considered and decided upon some end of life decisions and the appointments of those who they wish to make decisions for them when they are no longer able to do so. During this discussion with the client and the client's wife, the client states that 'my wife and I are legally married so I am so glad that she can automatically make all healthcare decisions on my behalf without a legal durable power of attorney when I am no longer able to do so myself' and the wife responds to this statement with, 'that is not completely true. I can only make decisions for you and on your behalf when these decisions are not already documented on your advance directive.' How should you, as the nurse, respond to and address this conversation between the husband and wife and the end of life?
- A. You should respond to the couple by stating that only unanticipated treatments and procedures that are not included in the advance directive can be made by the legally appointed durable power of attorney for healthcare decisions.
- B. You should be aware of the fact that the wife of the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need.
- C. You should be aware of the fact that the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need.
- D. You should reinforce the wife's belief that legally married spouses automatically serve for the other spouse's durable power of attorney for health care decisions and that others than the spouse cannot be legally appointed while people are married
Correct Answer: C
Rationale: The client's statement reflects a misunderstanding that a spouse automatically assumes the role of durable power of attorney for healthcare decisions without a legal designation. The wife's response is correct in that an advance directive takes precedence, and a durable power of attorney is only effective for decisions not covered by the advance directive. The nurse should recognize the client's knowledge deficit and plan education to clarify the roles of advance directives and durable power of attorney, as stated in option C.
An adult client has been admitted to the hospital with a 3-day history of uncontrolled vomiting and diarrhea. Which should the nurse assess for in this client? Select all that apply.
- A. Excitability
- B. Bradycardia
- C. Hypertension
- D. Poor skin turgor
- E. Flat peripheral veins
Correct Answer: D,E
Rationale: The client described in the question will most likely be dehydrated because of uncontrolled vomiting and diarrhea. The nurse assesses this client for weight loss, lethargy, or headache; sunken eyes; poor skin turgor (such as tenting); flat neck and peripheral veins; tachycardia; and low blood pressure.
The nurse is caring for a client post-cataract surgery. Which instruction should the nurse include in discharge teaching?
- A. Avoid bending at the waist
- B. Resume driving immediately
- C. Wear glasses at all times
- D. Sleep on the operative side
Correct Answer: A
Rationale: Avoiding bending at the waist prevents increased intraocular pressure, which could complicate recovery post-cataract surgery.
The nurse is caring for a client who has just undergone a cesarean section. Which of the following interventions is most important in the immediate postoperative period?
- A. Encouraging early ambulation.
- B. Administering oral fluids immediately.
- C. Monitoring for signs of infection.
- D. Applying heat to the incision site.
Correct Answer: A
Rationale: Encouraging early ambulation post-cesarean section prevents complications like deep vein thrombosis and promotes recovery.