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QUESTION NO: 1
A sixteen-year-old patient who speaks a little English has emergency gallbladder surgery.
During
discharge preparation, which nursing action would best help this patient understand wound care instruction?
A. Demonstrating the procedure and having the patient return the demonstration
B. Asking an interpreter to relay the instructions to the patient
C. Asking frequently if the patient understands the instruction
D. Writing out the instructions and having a family member read them to the patient
Answer: A
Explanation: During discharge preparation, the nursing action that would best help this patient understand
wound care instruction is demonstrating the procedure and having the patient return the demonstration.
This ensures that the patient can perform wound care correctly. The patient may claim to understand discharge instructions when they do not. An interpreter or family member may communicate verbal or
written instructions inaccurately.
QUESTION NO: 2
Mr. Collins is placed on digitalis on discharge from the hospital. The nurse planning with him for his
discharge should educate him as to the purpose and actions of his new medication. What should the nurse teach the patient to do at home to monitor his reaction to this medication?
A. Check his serum potassium (K) level
B. Weigh himself daily
C. Take his radial pulse for one full minute
D. Obtain his blood pressure
Answer: C
Explanation: What a nurse teaches the patient to do at home to monitor his reaction to this medication is
to take his radial pulse for one full minute. All other choices have some validity; however, option C relates
best to the action of the medication. If the pulse rate drops below 60 or is markedly irregular, the digitalis
should be held and the physician consulted.
QUESTION NO: 3
When planning discharge teaching for an adolescent patient who had an ileostomy, the nurse should
place primary emphasis on:
A. Informing the patient about the ileostomy association
B. Telling the patient whom to contact if assistance is needed
C. Encouraging the patient to return to school or work as soon as possible
D. Teaching the patient the importance of irrigations to regulate bowel movements
Answer: B
Explanation: When planning discharge teaching for an adolescent patient who had an ileostomy, the nurse should place primary emphasis on telling the patient whom to contact if assistance is needed.
The
patient should know there is help available, even though direct supervision is no longer provided.
QUESTION NO: 4
A seventeen-year-old female patient is receiving furosemide, 40 mg P.O. twice daily. In the plan of care,
the nurse should emphasize teaching the patient about the importance of consuming:
A. Lean red meat
B. Bananas and oranges
C. Fresh, green vegetables
D. Creamed corn
Answer: B
Explanation: In the plan of care, the nurse should emphasize teaching the patient about the importance of
consuming bananas and oranges. Because furosemide is a potassium-wasting diuretic, the nurse should
plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges.
Fresh,
green vegetables; lean red meat; and creamed corn are not good sources of potassium.
QUESTION NO: 5
A nurse is caring for patient who is scheduled for nephrectomy due to a renal cell carcinoma of the right
kidney. It appears that the left kidney is normal. The nurse observes that the patient is anxious and in doubt whether dialysis will ultimately be a necessity. The nurse should plan to use which information in
discussing this with the patient?
A. Dialysis could become likely, but it depends on how the patient complies with restrictions after the surgery
B. One kidney is adequate to meet the needs of the body, so long as it has a normal function
C. There is likelihood that the patient will need dialysis within the next 3-10 years
D. There is no need for dialysis because of the nature of the surgery
Answer: B
Explanation: When discussing this with the patient, the nurse should explain that one kidney is adequate
to meet the needs of the body, so long as it has a normal function. This patient needs emotional support
and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs.
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Updated: May 25, 2022