Nokea
A 55-year-old woman with end-stage metastatic cancer of the breast is admitted to the hospital. It is MOST important for the nurse to
- A. suction the patient frequently.
- B. provide an air mattress.
- C. turn the patient every two hours.
- D. give the patient frequent baths.
Correct Answer: C
Rationale: Turning every two hours prevents pressure ulcers in immobile cancer patients, a priority for skin integrity. Options A, B, and D are less critical unless specifically indicated.
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An elderly client who has just had a prosthetic hip implant.
The nurse should position the client
- A. with the affected hip internally rotated and flexed.
- B. with the affected hip adducted when turned.
- C. in the supine position with the knees elevated 90°.
- D. side-lying with the affected hip in a position of abduction.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (2) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (3) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (4) correct-position of abduction should be maintained
A client has been transferred from a nursing home to the hospital with an indwelling urinary catheter. The urine is cloudy and foul-smelling.
Which of the following nursing measures would be MOST appropriate?
- A. Clean the urinary meatus every other day.
- B. Encourage the client to increase fluid intake.
- C. Empty the drainage bag every 2-4 hours.
- D. Irrigate the Foley catheter every 8 hours.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the problem of the client's urine, should not be performed (2) correct-increasing intake of fluids is an appropriate independent nursing action that facilitates removal of concentrated urine (3) does not address the problem of the client's urine, should not be performed (4) could increase the chance of developing an infection
A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn findings suggests to the nurse that the infant has fetal alcohol syndrome?
- A. Growth retardation is evident
- B. Multiple anomalies are identified
- C. Cranial facial abnormalities are noted
- D. Prune belly syndrome is suspected
Correct Answer: C
Rationale: Cranial facial abnormalities are noted. Characteristic facial abnormalities are seen in the newborn with fetal alcohol syndrome.
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin detemir (Levemir) 15 units SC daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue
- B. Sweating and shakiness
- C. Occasional thirst
- D. Mild headache
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin detemir. Options A, C, and D are less urgent: fatigue is nonspecific, thirst is expected, and headache is common.
The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states 'I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax.' The client is using which defense mechanism?
- A. Denial
- B. Projection
- C. Intellectualization
- D. Rationalization
Correct Answer: D
Rationale: Rationalization. The client justifies drinking by providing acceptable explanations for unacceptable behavior.