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Questions 158

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Question 1 of 5

The nurse is caring for the client who has been in a coma for two months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?

Correct Answer: D

Rationale: Discussing organ donation with the wife while the client is still alive may cause distress, especially given her opposition. The nurse should refrain from raising the topic until after the client’s death, respecting her emotional state and hospital policy, which typically involves organ donation teams post-mortem.

Question 2 of 5

A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:

Correct Answer: D

Rationale: Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.

Question 3 of 5

The nurse is caring for a client with pneumonia who is allergic to penicillin. Which antibiotic is safest to administer to this client?

Correct Answer: C

Rationale: Erythromycin, a macrolide, is safe for penicillin-allergic patients. Cefazolin (
A), Amoxicillin (
B), and Ceftriaxone (
D) are beta-lactams with cross-reactivity risks.

Question 4 of 5

A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:

Correct Answer: C

Rationale: Cholelithiasis is the correct term used to describe the presence of stones in the gallbladder. Nephrolithiasis, or renal calculi, is the correct term used to describe the presence of stones in the kidney. Choledocholithiasis is the correct term used to describe the presence of stones in the common bile duct. Cholecystitis is the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.

Question 5 of 5

A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:

Correct Answer: D

Rationale: When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant is used, this layer is removed when the tape is removed.

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