Nokea
A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge?
- A. I will implement my exercise program as soon as I get home.'
- B. I will be careful not to cross my legs.'
- C. I will need an elevated toilet seat.'
- D. I can't wait to take a tub bath when I get home.'
Correct Answer: D
Rationale: Tub baths are contraindicated post-hip replacement due to the risk of hip flexion beyond 90 degrees, indicating a need for further teaching.
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On the first postpartum day, the nurse is caring for a primiparous client who has recently emigrated from Japan to the United States and speaks only a little English. The nurse observes that the client has been bottle-feeding her neonate on occasion, but most of the neonatal care is being performed by the client's mother-in-law. Which of the following actions would be most appropriate?
- A. Notify the social worker because bonding may be affected.
- B. Document the unusual maternal behavior in the client's chart.
- C. Determine whether this is a cultural practice for the client and her family.
- D. Obtain an order to make a home visit after the client's discharge.
Correct Answer: C
Rationale: Assessing whether the mother-in-law's involvement is a cultural practice respects the client's background and avoids misjudging normal family dynamics.
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
- A. Petal the edges of the cast with tape.
- B. Massage the skin at the rim of the cast.
- C. Shake a small amount of powder under the cast rim.
- D. Use a hair dryer set on a cool high setting to soothe the irritation.
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
A client with a history of chronic kidney disease is admitted with hyperkalemia. The nurse should prioritize which of the following interventions?
- A. Administer insulin and glucose.
- B. Restrict potassium-rich foods.
- C. Administer a loop diuretic.
- D. Monitor for dysrhythmias.
Correct Answer: D
Rationale: Monitoring for dysrhythmias is the priority, as hyperkalemia can cause life-threatening cardiac arrhythmias.
A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States?
- A. Organ and Tissue Procurement Organizations.
- B. American Transplant Association.
- C. American Hospice Foundation.
- D. American Association of Critical-Care Nurses.
Correct Answer: A
Rationale: Organ and Tissue Procurement Organizations are responsible for coordinating organ recovery in the United States, as they manage the donation process and ensure compliance with regulations.
A client with a diagnosis of breast cancer is prescribed letrozole (Femara). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of letrozole requiring immediate reporting.