Nokea
A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy?
- A. The client adducts the affected leg every 2 hours.
- B. The client rolls the affected leg away from the body's midline twice per day.
- C. The client performs isometric exercises to the affected extremity three times per day.
- D. The client asks the nurse to add a 5-lb weight to the traction for 30 minutes/day.
Correct Answer: C
Rationale: Isometric exercises maintain muscle strength without moving the immobilized leg.
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A health care provider has just inserted nasal packing for a client with epistaxis. The client is taking ramipril (Altace) for hypertension. What should the nurse instruct the client to do?
- A. Use 81 mg of aspirin daily for relief of discomfort.
- B. Omit the next dose of ramipril (Altace).
- C. Remove the packing if there is difficulty swallowing.
- D. Avoid rigorous aerobic exercise.
Correct Answer: D
Rationale: Avoiding rigorous aerobic exercise prevents increased blood pressure, which could worsen epistaxis. Aspirin increases bleeding risk. Omitting ramipril is not indicated without physician guidance. Removing packing is unsafe and should be done by a healthcare provider.
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: In pancreatitis, fluid sequestration into the retroperitoneal space (B) causes hypovolemia, complicating shock management. Intestinal hemorrhage (A), infection (C), and decreased cardiac output (D) are less primary contributors.
The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply.
- A. Determine that there will be a latex-safe environment for surgery.
- B. Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing).
- C. Notify the health care providers at the surgery center.
- D. Wear a stainless steel medical alert bracelet into the surgical suite.
- E. Ask to have the surgery at a hospital.
Correct Answer: A,B,C
Rationale: Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs/symptoms may be mild to anaphylaxis. Clients with latex allergy are advised to notify their health care providers and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current.
What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis?
- A. Don't worry. It's normal to feel that way.'
- B. Your friends are probably afraid of contracting hepatitis from you.'
- C. I'm sure you're imagining that!'
- D. Tell me more about your feelings of isolation.'
Correct Answer: D
Rationale: Encouraging the client to express feelings (D) fosters therapeutic communication and addresses emotional needs. Dismissing feelings (A, C) or assuming others' fears (B) is non-therapeutic and unhelpful.
An adult client with type 2 diabetes is taking metformin (Glucophage) 1,000 mg two times every day. After the nurse provides instructions regarding the interaction of alcohol and metformin, the nurse evaluates that the client understands the instructions when the client says:
- A. If I know I'll be having alcohol, I must not take metformin; I could develop lactic acidosis.'
- B. If my physician approves, I may drink alcohol with my metformin.'
- C. Adverse effects I should watch for are feeling excessively energetic, unusual muscle stiffness, low back pain, and a rapid heartbeat.'
- D. If I feel bloated, I should call my physician.'
Correct Answer: A
Rationale: Alcohol combined with metformin increases the risk of lactic acidosis, a serious complication. The client should avoid alcohol while taking metformin.