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Questions 164

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Question 1 of 5

Based on knowledge of cultural diversity, the nurse knows that obtaining a CBC will be most distressing for the client who is:

Correct Answer: D

Rationale: Some Native American cultures believe blood removal weakens the body or spirit, making a CBC distressing. Other groups typically do not have this belief.

Question 2 of 5

A client returns from surgery after having a suprapubic prostatectomy. Upon assessing the client, the nurse notes that his urine is bright red with many clots. Which of the following nursing actions is most appropriate?

Correct Answer: B

Rationale: Bright red urine with clots suggests a need to check the continuous bladder irrigation system to ensure it is functioning to prevent clot obstruction.

Question 3 of 5

An older adult is diagnosed with open-angle glaucoma. Which comment by the client indicates understanding of the management of the condition?

Correct Answer: A

Rationale: Daily eye drops control intraocular pressure in open-angle glaucoma, a chronic condition, indicating understanding, unlike expecting a cure, contagiousness, or immediate surgery.

Question 4 of 5

The nurse is talking with the parent of a 2-year-old client who has a sunburn across the back and shoulders. Which of the following statements by the parent would indicate a correct understanding of sunburn care? Select all that apply.

Correct Answer: A,C,D

Rationale: Extra fluids prevent dehydration, cool compresses soothe skin, and outdoor play with protection (sunscreen, clothing) is safe. Aspirin is avoided in children due to Reye's syndrome risk. Hydrocortisone isn't standard for sunburn; aloe or moisturizers are preferred.

Question 5 of 5

A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?

Correct Answer: A

Rationale: Lethargy. The level of consciousness or responsiveness is the most important measure of the client's rising intracranial pressure, requiring immediate attention.

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