Nokea
A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
- A. Encourage exercises in the unaffected extremities.
- B. Encourage her to cross and uncross her legs.
- C. Check neurological and circulatory status of the affected leg hourly.
- D. Place a trochanter roll along the upper thigh of the affected leg.
Correct Answer: B
Rationale: Exercising the unaffected extremities will prevent contractures and emboli. Crossing and uncrossing the affected leg after surgery can dislocate the joint. Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.
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The nurse is evaluating teaching effectiveness on a client with a gastrointestinal disorder prescribed a gluten-free diet. Which diet choice indicates that the client understands the instructions given?
- A. Steamed broccoli
- B. Wheat toast
- C. Chocolate chip cookie
- D. Bran cereal
Correct Answer: A
Rationale: Steamed broccoli is naturally gluten-free, indicating understanding of a gluten-free diet. Wheat toast (B), chocolate chip cookies (C), and bran cereal (D) contain gluten.
In preparation for the removal of the client's chest tubes, the nurse should instruct the client to:
- A. Breathe normally
- B. Hold his breath and bear down
- C. Take deep breaths
- D. Take shallow breaths
Correct Answer: B
Rationale: During chest tube removal, the client should hold their breath and bear down (Valsalva maneuver) to increase intrathoracic pressure, reducing the risk of air entering the pleural space.
After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?
- A. One centimeter below the ischial spines
- B. One centimeter above the ischial spines
- C. Has not entered the pelvic inlet yet
- D. Located in the pelvic outlet
Correct Answer: B
Rationale: Station refers to the relationship of the presenting part to the ischial spines. A station of -1 indicates the fetal head is 1 cm above the ischial spines.
Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
- A. Hemoglobin 17.2 g/dL
- B. Platelets 250,000/mm3
- C. Serum glucose 30 mg/dL
- D. White blood cells 18,000/mm3
Correct Answer: C
Rationale: A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which symptom is most characteristic?
- A. Hypertension
- B. Proteinuria
- C. Fetal macrosomia
- D. Painful vaginal bleeding
Correct Answer: A
Rationale: Hypertension (BP ≥140/90) is the defining symptom of gestational hypertension. Proteinuria indicates preeclampsia and fetal macrosomia or painful bleeding are unrelated.