Nokea
A client 2 days ago. What should the nurse include in the client's plan of care? Select all that apply.
- A. When using a walker, encourage the client to point the toes inward.
- B. Position a pillow between the legs to maintain abduction.
- C. Allow the client to be in the supine position or in the lateral position on the unoperated side.
- D. Do not allow the client to bend down to tie or slip on shoes.
- E. Place ice on the incision after physical therapy.
Correct Answer: B,C,D,E
Rationale: Positioning pillows for abduction, appropriate positioning, avoiding bending, and applying ice promote healing and prevent dislocation. Pointing toes inward is incorrect.
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A client post-cystectomy is at risk for:
- A. Vitamin B12 deficiency.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Dehydration.
Correct Answer: A
Rationale: Cystectomy may impair vitamin B12 absorption due to ileum resection.
A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal to address for the client is:
- A. Fear of pain.
- B. Fear of further therapy.
- C. Feelings of isolation.
- D. Feelings of social inadequacy.
Correct Answer: A
Rationale: In hospice care for advanced Hodgkin's disease, the primary goal is to address fear of pain, ensuring comfort as death approaches. Fear of therapy, isolation, and social inadequacy are less relevant at this stage.
The nurse should teach the neutropenic client and the family to avoid which of the following?
- A. Using suppositories or enemas.
- B. Using a high-efficiency particulate air (HEPA) filter mask.
- C. Performing perianal care after every bowel movement.
- D. Performing oral care after every meal.
Correct Answer: A
Rationale: Neutropenic clients should avoid suppositories or enemas, as they can cause rectal trauma and introduce infections. HEPA masks, perianal care, and oral care are recommended to reduce infection risk.
A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Maintain the head of the bed at 30 to 40 degrees.
- B. Teach the client how to use esophageal speech.
- C. Initiate small feedings of soft goods.
- D. Irrigate drainage tubes as needed.
Correct Answer: A
Rationale: Elevating the head of the bed 30–40 degrees reduces swelling and maintains airway patency post-laryngectomy. Esophageal speech training is premature immediately post-surgery. Feedings are typically delayed until swallowing is safe. Drainage tubes are not routinely irrigated.
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (A) is essential to identify etiology. Interference with tests (B), general alcoholism screening (C), or disregarding beliefs (D) are not accurate explanations.