Teaching and Learning
Home / Nursing & Allied Health Certifications / NCLEX RN / Nursing Process
Question 1 of 5.
The nurse has provided instructions to a client who is receiving external radiation therapy. Which statement by the client indicates a need for further teaching regarding self-care related to the radiation therapy?
A. I need to eat a high-protein diet.
B. I need to avoid exposure to sunlight.
C. I need to wash my skin with a mild soap and pat it dry.
D. I need to apply pressure on the irritated area to prevent bleeding.
Explanation: The client receiving external radiation therapy should avoid pressure on the irritated area and wear loose-fitting clothing. Specific health care provider instructions would be necessary to obtain if an alteration in skin integrity occurred as a result of the radiation therapy. The remaining options are accurate measures regarding radiation therapy.
Question 2 of 5.
The nurse is providing discharge teaching for a client diagnosed and treated for tuberculosis (TB). Which statement by the client indicates that teaching has been effective? Select all that apply.
A. All used dishes should be sterilized.
B. My close contacts should be tested for TB.
C. Soiled tissues should be disposed of properly.
D. House isolation is required for at least 8 months.
E. The mouth should always be covered when coughing.
Explanation: Tuberculosis is a communicable disease, and the nurse must teach the client measures to prevent its spread. Any close contacts with the client must be tested and treated if the results of the screening test are positive. Because it is an airborne disease, the client must properly dispose of used tissues and needs to cover the mouth when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the house. Once the client is treated and results of three sputum cultures are negative, the client will not spread the infection.
Question 3 of 5.
A client is receiving intravenous (IV) antibiotic therapy at home via an intermittent IV catheter. In order to facilitate the early detection of IV therapy complications, which intervention should be included in the client's education?
A. Protect the IV site continually.
B. Keep the IV site clean and dry.
C. Report local pain, drainage, or edema.
D. Apply pressure to the IV site if it dislodges.
Explanation: The nurse instructs the client to report clinical indicators of an IV site infection, including pain, drainage, and edema because the early detection of infection decreases the risk of septicemia, tissue loss, and devastating complications. The remaining options are reasonable aspects of client teaching for IV therapy at home, but they are not surveillance methods.
Question 4 of 5.
The home care nurse provides instructions about the management of pruritus to a client diagnosed with jaundice. Which statement made by the client suggests to the nurse that the client needs further teaching?
A. I need to wear loose cotton clothing.
B. A tepid water bath should help stop the itching.
C. Keeping the house warmer is likely to lessen the itching
D. I need to take the prescribed antihistamines as I'm supposed to.
Explanation: Pruritus is caused by the accumulation of bile salts in the skin and results from obstructed biliary excretion. The client would be instructed to keep the house temperature cool in order to minimize the itching. The client should avoid the use of alkaline soap, and he or she (client) should wear loose, soft, cotton clothing. Antihistamines may relieve the itching, as will tepid water and emollient baths.
Question 5 of 5.
The nurse has provided home care instructions to a client with prostate cancer who has been hospitalized for a transurethral resection of the prostate (TURP). Which statement by the client indicates the need for further teaching?
A. Prune juice needs to be included in my diet.
B. I need to avoid strenuous activity for 4 to 6 weeks.
C. My intake of water needs to be at least 6 to 8 glasses daily.
D. I can't lift or push objects that weigh more than 30 pounds.
Explanation: The client needs to be advised to avoid strenuous activity for 4 to 6 weeks and avoid lifting items that weigh more than 20 pounds. Straining during defecation is avoided to prevent bleeding. Prune juice is a satisfactory bowel stimulant. The client needs to consume a daily intake of at least 6 to 8 glasses of nonalcoholic fluids to minimize clot formation.
Related Questions