Nokea
The nurse is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical exercises with the physical therapy department?
- A. Before bedtime, at 2000
- B. After breakfast
- C. Before the evening meal
- D. After lunch
Correct Answer: B
Rationale: Scheduling physical exercises after breakfast is the optimal choice for a client with Myasthenia Gravis. This timing allows the client to benefit from renewed energy levels after overnight rest and intake of morning nourishment, enhancing the effectiveness of the therapy session. Choices A (Before bedtime, at 2000) is not suitable as energy levels are likely lower at night, affecting the client's ability to engage effectively in physical exercises. Choices C (Before the evening meal) and D (After lunch) may not be ideal as the client may experience fatigue or weakness later in the day, making it harder to participate actively in therapy.
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A client with a diagnosis of bipolar disorder is prescribed lithium. Which electrolyte imbalance should the nurse monitor for?
- A. Hyponatremia
- B. Hypokalemia
- C. Hypercalcemia
- D. Hypernatremia
Correct Answer: A
Rationale: The correct answer is A: Hyponatremia. Lithium can affect sodium levels in the body, potentially leading to hyponatremia, which is a condition characterized by low sodium levels. This imbalance requires close monitoring as it can lead to symptoms such as confusion, weakness, and even seizures. Choices B, C, and D are incorrect because lithium is not primarily associated with causing hypokalemia, hypercalcemia, or hypernatremia. While these imbalances can occur in certain conditions or with other medications, the main electrolyte imbalance to monitor when a client is prescribed lithium is hyponatremia.
What is the most important aspect of colostomy care to teach the client?
- A. Change the colostomy bag daily
- B. Irrigate the colostomy daily
- C. Avoid high-fiber foods
- D. Assess the stoma for color and swelling
Correct Answer: D
Rationale: The most crucial aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is essential to detect early signs of complications such as ischemia or infection. Changing the colostomy bag daily is important but not as critical as assessing the stoma for complications. Irrigating the colostomy daily is not a standard recommendation and should be performed based on healthcare provider's instructions. While avoiding high-fiber foods may be beneficial for some individuals with a colostomy, it is not the most important aspect of care compared to monitoring the stoma for complications.
The nurse is preparing to administer a subcutaneous injection of heparin. What is the correct angle of insertion?
- A. 15 degrees
- B. 30 degrees
- C. 45 degrees
- D. 90 degrees
Correct Answer: C
Rationale: The correct angle of insertion for a subcutaneous injection, such as heparin, is 45 degrees. This angle is appropriate as it helps to ensure proper delivery of the medication into the subcutaneous tissue. Option A (15 degrees) is too shallow for a subcutaneous injection and may result in the medication being deposited into the muscle. Option B (30 degrees) is also too shallow for subcutaneous injections. Option D (90 degrees) is used for intramuscular injections, not subcutaneous injections.
What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter?
- A. Irrigate the catheter daily.
- B. Change the catheter every 72 hours.
- C. Apply antibiotic ointment at the insertion site.
- D. Ensure the catheter bag is always below bladder level.
Correct Answer: D
Rationale: The most crucial action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter is to ensure that the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Irrigating the catheter daily (Choice A) is unnecessary and can introduce pathogens. Changing the catheter every 72 hours (Choice B) is not recommended unless clinically indicated to prevent introducing new pathogens. Applying antibiotic ointment at the insertion site (Choice C) is not the most important action to prevent CAUTIs; proper hygiene and maintaining a closed system are more critical.
Based on the documentation in the medical record, which action should the nurse implement next?
- A. Administer the rubella vaccine subcutaneously
- B. Observe the mother breastfeeding her infant
- C. Call the nursery for the infant's blood type result
- D. Administer Vicodin one tablet for pain
Correct Answer: B
Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.