A nurse is providing discharge teaching to a client who just had a cholecystectomy. Which of the following statements by the client indicate that further education is required?

• "I'll call my doctor if I notice a sudden increase in drainage or if it starts to smell really bad."
• "I will keep my T-tube clamped at all times."
• "I'll make sure to decrease the amount of fat in my diet."
• "I expect for my stool to return to the normal color is about seven days."

The nurse is caring for a client who has returned to the floor from the PACU after an appendectomy. Based on this surgical procedure, the nurse knows to implement which of the following interventions for this client?

• Apply heat to the abdomen to promote comfort
• Monitor temperature and pulse to assess for infection
• Delay assessment of the incision until 24 hours post-op to prevent infection
• Encourage favorite foods to encourage the return of bowel function

A 69-year-old client has been diagnosed with aspiration pneumonia after suffering from a chronic illness. The nurse is teaching the client about how to best perform exercises for pulmonary hygiene. Which of the following should the nurse include as part of teaching?

• Place your hands across your abdomen, take a deep breath, and cough
• Turn from side to side in bed every 4 hours
• Breathe in through your mouth and out through your nose
• Lean forward in bed and raise your arms above your head

A nurse is working with a client who has been infected with methicillin-resistant staphylococcus aureus (MRSA). The nurse needs to check the client’s vital signs using a blood pressure cuff that is normally kept in the central supply area of the unit. Which action should the nurse perform that is most appropriate to prevent spread of this infection?

• Return the cuff to central supply after wiping it down with an alcohol wipe
• Send the cuff to sterile supply for heated sterilization before using it again
• Contact housekeeping for industrial cleaners to use on the cuff
• Keep the equipment in the room with the client during his hospitalization

A student nurse is observing the preceptor insert a urinary catheter into a male. Which of the following actions is the first action the preceptor will perform after placing the waterproof drape and fenestrated drape on the client?

• Pour povidone-iodine over the cotton swabs
• Attach foley bag to the bed below the waist
• Don sterile gloves
• Insert the catheter into the client's meatus

A nurse is caring for a client admitted for rhabdomyolysis after being found lying on the floor for three days. Which of the following orders should the nurse expect to implement?

• Keep legs elevated
• Strict intake and output
• NPO
• Fluid restriction

The nurse receives report on a client who will be coming to the floor following a TURP (transurethral resection of the prostate). The nurse prepares for the client’s arrival by gathering which of the following supplies for continuous bladder irrigation? Select all that apply.

• 3,000 mL bags of 0.9% saline
• A urinal
• 3-way blood tubing
• IV pole
• Infusion pump

The nurse is caring for an older adult client who has a urinary tract infection. The client has mild dementia, is confused but easily reoriented, and continues to attempt to get out of bed. Which of the following is an appropriate safety measure for this client? Select all that apply.

• A bed alarm on the most sensitive setting
• A sitter
• Bilateral soft wrist restraints
• 5 mg IV haloperidol
• Non-skid footwear

The nurse is caring for a client who has a kidney stone. Which of the following foods should the nurse teach the client to avoid? Select all that apply.

• Grapes
• Rice
• Chocolate
• Potato chips
• Milk

A nurse is monitoring her client who is in the medical-surgical unit with a recent bowel resection. The client has an infusion of TPN with lipids running into a central line. Which of the following metabolic complications would the nurse most likely see with a client receiving TPN?

• Hypoalbuminemia
• Hypertriglyceridemia
• Hypermagnesemia
• Hyponatremia