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1. A client who is to undergo a colonoscopy is being taught by a nurse about the procedure. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will drink liquids right up until the procedure.
- B. I will need to stop eating and drinking at least 24 hours before the procedure.
- C. I will be sedated and will not feel any pain during the procedure.
- D. I will not need to follow any specific dietary restrictions for this procedure.
Correct answer: C
Rationale: Choice C is the correct answer. During a colonoscopy, clients are typically sedated, so they do not feel any pain during the procedure. Choices A, B, and D are incorrect. Clients are usually required to stop eating and drinking at least 24 hours before a colonoscopy, and there are specific dietary restrictions that need to be followed before the procedure to ensure a successful examination.
2. When providing discharge instructions for a client with home oxygen, what safety measure should the nurse emphasize?
- A. Prohibit smoking near oxygen equipment
- B. Ensure the client uses non-flammable bedding
- C. Ensure oxygen tanks are stored upright
- D. Keep the oxygen equipment at least 6 feet away from heat sources
Correct answer: D
Rationale: The correct answer is to keep the oxygen equipment at least 6 feet away from heat sources. Placing oxygen equipment near heat sources can lead to fire hazards due to the oxygen's combustible nature. Option A is the correct safety measure as smoking near oxygen equipment can cause fires due to oxygen's flammable properties. Option B regarding the use of non-flammable bedding is not directly related to oxygen safety. Option C is important for proper oxygen tank functioning but is not as critical as keeping the equipment away from heat sources to prevent fires.
3. What are the key signs of infection after surgery?
- A. Redness
- B. Swelling
- C. Fever
- D. All of the above
Correct answer: D
Rationale: After surgery, key signs of infection include redness, swelling, and fever. Redness and swelling can indicate inflammation at the surgical site, while fever is a systemic response to infection. Choosing 'All of the above' (Option D) is the correct answer because all three signs are commonly associated with post-surgical infections. Options A, B, and C are incorrect as each of them individually can be a sign of infection, but considering all three together provides a more comprehensive assessment for post-operative infection.
4. A patient took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the patient?
- A. Naloxone
- B. Acetylcysteine
- C. Flumazenil
- D. Activated charcoal
Correct answer: B
Rationale: Acetylcysteine is the antidote for acetaminophen overdose. It works by replenishing glutathione, a key component in detoxifying acetaminophen metabolites, thus preventing liver damage. Naloxone is used to reverse opioid overdose, not acetaminophen. Flumazenil is a benzodiazepine antidote. Activated charcoal is used to limit absorption in cases of poisoning, but it is not the antidote for acetaminophen overdose.
5. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?
- A. Increased speech
- B. Lack of sleep
- C. Agitation
- D. Poor concentration
Correct answer: B
Rationale: The correct answer is lack of sleep (choice B). In acute mania, lack of sleep can exacerbate symptoms, lead to exhaustion, and pose serious risks to the client's well-being. Addressing the client's sleep deprivation is a priority as it can impact their overall health and recovery. Increased speech (choice A) and agitation (choice C) are common in acute mania but do not pose immediate physical risks like lack of sleep. Poor concentration (choice D) is also a symptom of acute mania but addressing sleep deprivation takes precedence due to its severe consequences.
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