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A client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Position the client supine with a pillow between the legs.
- B. Place an abduction pillow between the client's legs.
- C. Place a pillow under the client's knees.
- D. Position the client's legs in adduction.
Correct Answer: B
Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.
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A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an incident report?
- A. A client receives antibiotics 2 hours late.
- B. A client vomits within 20 minutes of taking morning medications.
- C. A client requests a statin to be administered at 2100.
- D. A client asks for pain medication 1 hour early.
Correct Answer: A
Rationale: The correct answer is A. Administering antibiotics late must be reported as it can compromise the effectiveness of the treatment. This delay can lead to subtherapeutic levels of the antibiotic in the client's system, potentially reducing its efficacy in combating the infection. Choice B, a client vomiting shortly after taking medication, should be noted but does not necessarily require an incident report unless it is a frequent occurrence. It could indicate a possible adverse reaction or intolerance to the medication. Choice C, a client requesting a statin at a specific time, and choice D, a client asking for pain medication slightly earlier, do not involve medication errors or deviations that pose immediate risks to the client's health, so they do not require incident reports.
A client with a new diagnosis of systemic lupus erythematosus (SLE) is being cared for by a nurse. Which of the following findings should the nurse expect?
- A. Joint pain.
- B. Weight gain.
- C. Butterfly-shaped rash on the face.
- D. Increased appetite.
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Weight gain is a common finding in clients with systemic lupus erythematosus due to fluid retention. Joint pain (choice A) is also common in SLE but is not specific to fluid retention. A butterfly-shaped rash on the face (choice C) is a classic symptom of SLE but is not related to fluid retention. Increased appetite (choice D) is less likely in SLE compared to weight gain.
A nurse is assessing a client who is immediately postoperative following a subtotal thyroidectomy. Which of the following should the nurse expect to administer?
- A. Calcium gluconate
- B. Sodium bicarbonate
- C. Potassium chloride
- D. Sodium phosphate
Correct Answer: A
Rationale: Calcium gluconate is the correct answer because it is administered to treat hypocalcemia, a common complication post-thyroidectomy. After a thyroidectomy, there is a risk of damaging the parathyroid glands, which can lead to a decrease in calcium levels. Administering calcium gluconate helps to raise calcium levels. Sodium bicarbonate (Choice B) is not typically indicated for immediate postoperative care following a subtotal thyroidectomy. Potassium chloride (Choice C) is not directly related to the common complications of this specific surgery. Sodium phosphate (Choice D) is not typically used to address immediate postoperative issues post-thyroidectomy.
A nurse is preparing to administer an IM injection to a client. Which of the following actions should the nurse take?
- A. Massage the injection site after administering the medication.
- B. Insert the needle at a 45° angle.
- C. Use a Z-track technique to administer the injection.
- D. Aspirate for blood before injecting the medication.
Correct Answer: C
Rationale: The correct answer is C: 'Use a Z-track technique to administer the injection.' When administering IM injections, using a Z-track technique helps prevent medication from leaking into subcutaneous tissues. This technique involves pulling the skin laterally, injecting the medication deeply into the muscle, and then releasing the skin. Choice A is incorrect because massaging the injection site after administering the medication can lead to increased blood flow and potential leakage of the medication. Choice B is incorrect as the needle should typically be inserted at a 90° angle for IM injections to ensure proper delivery into the muscle. Choice D is incorrect as aspirating for blood before injecting the medication is not routinely recommended for IM injections.
A healthcare provider is assessing a client who has bacterial meningitis. Which of the following findings should the healthcare provider expect?
- A. Nuchal rigidity.
- B. Flaccid paralysis.
- C. Bradycardia.
- D. Hypothermia.
Correct Answer: A
Rationale: Nuchal rigidity is a classic sign of bacterial meningitis and indicates inflammation of the meninges. It is characterized by neck stiffness and pain upon neck flexion. Flaccid paralysis (Choice B) is not typically associated with bacterial meningitis but rather conditions like Guillain-Barre syndrome. Bradycardia (Choice C) and hypothermia (Choice D) are not commonly seen in bacterial meningitis; instead, patients may present with fever, tachycardia, and signs of systemic inflammation.