Nokea
The nurse is caring for a client who is post-op after a hip replacement. Which of the following nursing actions is most appropriate to prevent dislocation of the hip?
- A. Place an abduction pillow between the client's legs.
- B. Use an abduction pillow between the client's legs.
- C. Encourage the client to cross their legs while sitting.
- D. Encourage the client to sit upright for long periods.
Correct Answer: B
Rationale: Using an abduction pillow between the client's legs is the most appropriate nursing action to prevent dislocation after hip replacement surgery. An abduction pillow helps maintain proper alignment and prevents the hip from dislocating. Placing the client in a high Fowler's position (Choice A) or encouraging them to sit upright for long periods (Choice D) may not provide the necessary support and stability needed to prevent hip dislocation. Encouraging the client to cross their legs while sitting (Choice C) can increase the risk of hip dislocation and should be avoided.
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An unresponsive male victim of a diving accident is brought to the emergency department where immediate surgery is required to save his life. No family members are available. What action should the nurse take first?
- A. Ask the friend to sign an informed consent.
- B. Notify the unit manager that a court order is needed.
- C. Continue providing life support until a guardian is found.
- D. Proceed with surgery preparation without consent.
Correct Answer: D
Rationale: In emergency situations where immediate surgery is required to save a patient's life and no family members are available, consent can be waived to proceed with necessary interventions. The priority in this scenario is to proceed with surgery preparation without waiting for consent, as any delay could jeopardize the patient's life. Asking the friend to sign informed consent or notifying the unit manager for a court order would cause unnecessary delays, which are not advisable in this critical situation. Continuing life support until a guardian is found is not the most appropriate action when immediate surgical intervention is necessary.
A male client with HIV on antiretroviral therapy complains of constant hunger and thirst while losing weight. What action should the nurse implement?
- A. Check the client's glucose level with a glucometer.
- B. Measure the client's weight accurately.
- C. Reassure the client that weight will stabilize as viral load decreases.
- D. Increase the dose of saquinavir.
Correct Answer: A
Rationale: The correct action for the nurse to implement is to check the client's glucose level with a glucometer. Constant hunger and thirst along with weight loss can be indicative of hyperglycemia, a possible side effect of saquinavir. Monitoring the client's glucose levels is crucial in this situation. Measuring the client's weight accurately (Choice B) is important for monitoring purposes but does not address the immediate concern of hunger, thirst, and weight loss. Reassuring the client that weight will stabilize as viral load decreases (Choice C) is not appropriate in this scenario as the symptoms described need immediate attention. Increasing the dose of saquinavir (Choice D) without assessing the client's glucose level can worsen the hyperglycemia.
A nurse is caring for a 73-year-old male client with Alzheimer's disease. Which action should the nurse take to enhance the client's nutritional intake?
- A. Encourage the client to eat large meals in one sitting.
- B. Offer the client frequent snacks of foods he enjoys.
- C. Provide the client with foods high in fiber to improve digestion.
- D. Discourage eating late at night to prevent weight gain.
Correct Answer: B
Rationale: Offering frequent snacks of foods the client enjoys is the most appropriate action to enhance the nutritional intake of a client with Alzheimer's disease. This approach helps to ensure that the client receives an adequate amount of nutrients throughout the day, especially when larger meals might be challenging for individuals with Alzheimer's. Encouraging large meals in one sitting (Choice A) may overwhelm the client and lead to decreased food intake. While foods high in fiber (Choice C) are beneficial for digestion, the primary focus should be on providing foods the client enjoys to increase intake. Discouraging eating late at night (Choice D) is not directly related to enhancing nutritional intake in this scenario.
A male client with schizophrenia is socially reclusive and pacing in the hallway. What is the most important intervention for the nurse to implement?
- A. Take the client's temperature and blood pressure.
- B. Encourage the client to rest.
- C. Plan an activity that includes physical exercise.
- D. Carefully observe the client throughout the shift.
Correct Answer: D
Rationale: The correct answer is to carefully observe the client throughout the shift. In this situation, the client's behavior suggests agitation and restlessness, which could potentially escalate. Observation is crucial to monitor any changes in behavior, assess for signs of distress, and ensure the client's safety. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for managing the client's behavior. Encouraging the client to rest (Choice B) might not be effective if the client is highly agitated. Planning an activity that includes physical exercise (Choice C) could exacerbate the situation rather than address the current behavior. Therefore, the priority is to observe the client closely to provide appropriate support and intervention as needed.
A client with dysphagia is having difficulty swallowing medications. What is the nurse's best intervention?
- A. Crush the medications and mix them with applesauce.
- B. Encourage the client to drink water with each dose.
- C. Consult with the healthcare provider about switching to liquid medications.
- D. Offer the client soft foods to reduce difficulty swallowing.
Correct Answer: C
Rationale: The best intervention for a client with dysphagia experiencing difficulty swallowing medications is to consult with the healthcare provider about switching to liquid medications. Liquid medications are often easier to swallow and can reduce the risk of choking and aspiration in clients with dysphagia. Crushing medications can alter their effectiveness, encouraging the client to drink water may not be sufficient, and offering soft foods is not directly related to improving medication swallowing.