Nokea
A nurse is preparing discharge instructions for a client with a below-the-knee amputation. Which instruction would be a priority?
- A. sterile wound management
- B. elevation of residual limb
- C. performing prescribed exercises
- D. reporting occurrence of phantom limb pain immediately
Correct Answer: B
Rationale: Elevating the residual limb (B) is the priority to reduce edema and promote healing post-amputation. Wound care (A), exercises (C), and phantom pain (D) are important but secondary.
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The nurse is assisting the health care provider to perform a renal biopsy. Which position should the nurse place the client in?
- A. in the semi-Fowler's position
- B. on the same side of the kidney to be biopsied
- C. on the side opposite of the kidney to be biopsied
- D. prone with a pillow under the shoulders and abdomen
Correct Answer: D
Rationale: The prone position with a pillow under the abdomen (D) provides optimal access to the kidney and stabilizes the client during a renal biopsy.
A student nurse is discussing fluid overload with the staff nurse. Which statement by the student nurse indicates a need for further explanation by the staff nurse?
- A. Pitting edema is the best indicator of fluid overload.
- B. The client may have distended veins in the hands and neck.
- C. I may hear moist crackles in the lungs during my respiratory assessment.
- D. The client may need drug therapy and sodium restriction to treat the overload.
Correct Answer: A
Rationale: Pitting edema is one indicator, but not the best, as fluid overload is assessed holistically (e.g., crackles, distended veins). Other statements are accurate.
The nurse is preparing the client for a liver biopsy. Which statement by the client indicates a need for further instruction regarding the procedure?
- A. I can resume strenuous activity in 2 to 3 days.
- B. I will have to lay on my right side after the procedure.
- C. I will have a small bandage instead of stitches afterward.
- D. My right shoulder may begin to hurt as the anesthesia wears off.
- E. I may have a small amount of pain or discomfort during the procedure.
Correct Answer: A
Rationale: Strenuous activity should be avoided for 1-2 weeks post-liver biopsy to prevent bleeding, indicating a need for further teaching.
A 10-year-old is sent home from school with a report of having lice. The nurse should instruct the parent on which intervention?
- A. wash the hair for three continuous days with dandruff shampoo
- B. isolate all clothing of the child for one week
- C. treat with an approved pediculicide agent according to directions
- D. shave the child's head, then cleanse with herbal shampoo
Correct Answer: C
Rationale: An approved pediculicide (C) is the standard treatment for head lice, following package directions. Dandruff shampoo (A) is ineffective, isolation alone (B) is insufficient, and shaving (D) is unnecessary.
The nurse is caring for a homeless client brought to the emergency department with a diagnosis of heat stroke. Which key features of heat stroke would the nurse expect to note upon assessment? Select all that apply.
- A. a body temperature of 104.2°F
- B. heart rate of 116 and blood pressure of 78/52
- C. heart rate of 49 and blood pressure of 152/90
- D. heart rate of 120 and respiratory rate of 9 breaths per minute
- E. blood pressure of 82/48 and respiratory rate of 26 breaths per minute
Correct Answer: A,B,E
Rationale: Heat stroke presents with hyperthermia (>104°F, A), tachycardia and hypotension (B, E) due to dehydration and vasodilation. Bradycardia (C) and low respiratory rate (D) are not typical.