Nokea
A client has been in the position shown in the figure for surgery. The nurse should document that the client has been in which of the following positions?
- A. Reverse Trendelenburg.
- B. Low Fowler’s.
- C. High lithotomy.
- D. Prone.
Correct Answer: C
Rationale: The client is in the lithotomy position. The reverse Trendelenburg position is when the client is lying supine with the head lower than the rest of the body. A low Fowler’s position is when the client is sitting up at a 30- to 45-degree angle. The prone position is when the client is lying face down.
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The nurse is conducting discharge education with a client newly diagnosed with Addison's disease. Which information should be included in the client and family teaching plan? Select all that apply.
- A. Addison's disease will resolve over a few weeks, requiring no further treatment.
- B. Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations.
- C. Fatigue, weakness, dizziness, and mood changes need to be reported to the physician.
- D. A medical identification bracelet should be worn.
- E. Family members need to be informed about the warning signals of adrenal crisis.
- F. Dental work or surgery will require adjustment of daily medication.
Correct Answer: B,C,D,E,F
Rationale: Addison's is chronic, requiring lifelong management. Stress management, symptom reporting, medical ID, family education, and medication adjustments for procedures are critical.
The nurse is assessing a client's nutritional status preoperatively. Which of the following observations would indicate poor nutrition in a 5-foot 7-inch female client who is 21 years of age?
- A. Poor posture.
- B. Little mass.
- C. Dull expression.
- D. Weight of 128 lb (58.1 kg).
Correct Answer: B
Rationale: Little mass in a 5'7' female suggests low body weight or muscle wasting, indicative of poor nutrition. A weight of 128 lb is within a healthy range, and poor posture or dull expression are less specific to nutritional status.
The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
- A. If I limit my fluid intake, I will not have to empty my ostomy pouch as often.
- B. I can place an aspirin tablet in my pouch to decrease odor.
- C. I can usually keep my ostomy pouch on for 3 to 7 days before changing it.
- D. I must use a skin barrier to protect my skin from urine.
- E. I should supply my ostomy pouch of urine when it is full.
Correct Answer: C,D
Rationale: Keeping the pouch on for 3-7 days and using a skin barrier are correct practices. Limiting fluids increases infection risk, aspirin is unsafe, and the last option is unclear but likely a typo for emptying when full, which is correct but not listed as such.
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 should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a:
- A. Low sodium level.
- B. High glucose level.
- C. High calcium level.
- D. Low potassium level.
Correct Answer: D
Rationale: Low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing digoxin's binding to cardiac cells, leading to arrhythmias.