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A nurse is teaching a client with left-sided hemiparesis to walk with a cane. The nurse should include which points about safe cane use when teaching the client? Select all that apply.
- A. hold the cane in the right hand
- B. hold the cane in the left hand
- C. move the cane and step forward with the right leg
- D. move the cane and step forward with the left leg
Correct Answer: A,C
Rationale: For left-sided hemiparesis, the cane is held in the stronger right hand (A), and the cane moves with the weaker right leg (C) for support. Left hand (B) and left leg (D) are incorrect.
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The nurse is caring for an adult client with a total bilirubin of 2.1 mg/dL. Which signs and symptoms would the nurse expect to find? Select all that apply.
- A. itchy skin
- B. nausea
- C. pale stools
- D. colorless urine
- E. none; this is a normal lab value
Correct Answer: A,C
Rationale: Elevated bilirubin (2.1 mg/dL, normal 0.1-1.2) causes itchy skin (A) and pale stools (C) due to biliary obstruction or liver dysfunction. Nausea (B) is less specific, and urine is typically dark, not colorless (D).
The nurse is educating a client who has been ordered to wear a Holter monitor. Which statement by the client indicates a need for further education by the nurse?
- A. I can wear the monitor while I shower.
- B. I should keep the monitor on when I sleep.
- C. I should avoid metal detectors and electric razors while wearing the monitor.
- D. I should keep a log of any chest pain, shortness of breath, or skipped beats while wearing the monitor.
Correct Answer: A
Rationale: Holter monitors are not waterproof and should not be worn while showering, indicating a need for further teaching.
The nurse is performing discharging instruction for a female client with cystitis. Which statement by the client indicates a need for further teaching?
- A. I should void before and after intercourse.
- B. I should wear loose-fitting cotton underwear.
- C. I can continue using spermicide for birth control.
- D. If I have burning when I urinate, I will contact my physician.
Correct Answer: C
Rationale: Spermicides can irritate the urethra and increase UTI risk, requiring further teaching. Other statements align with cystitis prevention and management.
A client is having a tonic-clonic seizure. Which of the following should the nurse do first?
- A. call for assistance
- B. restrain the client
- C. turn the client on her side
- D. provide a safe environment
Correct Answer: D
Rationale: During a tonic-clonic seizure, the priority is to provide a safe environment (D) by removing hazards to prevent injury. Restraining (B) is unsafe, and turning (C) or calling (A) follow safety measures.
The nurse is caring for a client in the cardiac unit and notices the client's rhythm changes from normal sinus rhythm to coarse ventricular fibrillation. Which is the priority nursing action?
- A. call a code blue
- B. check the client and check the leads
- C. initiate CPR while waiting on help to arrive
- D. prepare to start the client on a diltiazem (Cardizem) drip
- E. clear the room of unnecessary items to allow room for the crash cart and team
Correct Answer: C
Rationale: Ventricular fibrillation is a life-threatening arrhythmia requiring immediate CPR (C) to restore circulation until defibrillation is available.