Nokea
A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should:
- A. Position the client on a firm mattress
- B. Keep the involved extremity warm with blankets
- C. Position the left leg at or below the body's horizontal plane
- D. Encourage the client to raise and lower his leg four times every hour
Correct Answer: C
Rationale: Positioning the left leg at or below the body's horizontal plane promotes arterial blood flow to the extremity in arteriosclerosis, avoiding gravitational resistance. A firm mattress is irrelevant, warmth is beneficial but secondary, and leg raises may not be feasible pre-revascularization.
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Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress?
- A. Administering oxygen every 2 hours.
- B. Turning the client every 4 hours.
- C. Administering sedatives to promote rest.
- D. Suctioning if cough is ineffective.
Correct Answer: D
Rationale: Suctioning clears secretions when coughing is ineffective in ARDS, maintaining airway patency. Oxygen delivery, turning, and sedatives are supportive but less direct for airway clearance.
A client with a spinal cord injury is at risk for pressure ulcers. Which nursing intervention is most effective?
- A. Reposition the client every 4 hours.
- B. Use a foam mattress without a cover.
- C. Apply lotion to bony prominences daily.
- D. Turn the client every 2 hours.
Correct Answer: D
Rationale: Turning every 2 hours redistributes pressure, preventing ulcer formation in immobilized clients.
A nurse is caring for a client who is prescribed a medication with a narrow therapeutic index (NTI). Which action should the nurse take when administering this medication?
- A. Administer the medication as prescribed, ensuring strict adherence to the dosing schedule.
- B. Administer the medication concurrently with herbal supplements to augment its efficacy.
- C. Combine the medication with other medications to enhance its therapeutic effects.
- D. Administer the medication at a higher dose than prescribed to achieve faster results.
Correct Answer: A
Rationale: NTI medications require strict adherence to dosing to maintain therapeutic levels and avoid toxicity.
Which outcome is appropriate for a client with a traumatic brain injury?
- A. Complete memory recovery.
- B. Active participation in therapy.
- C. Return to pre-injury job.
- D. Eliminate all symptoms.
Correct Answer: B
Rationale: Active participation in therapy is a realistic outcome for recovery in traumatic brain injury.
After teaching the client with severe rheumatoid arthritis about prescribed methotrexate (Rheumatrex), which of the following statements indicates the need for further teaching?
- A. I will take my vitamins while I'm on this drug.'
- B. I must not drink any alcohol while I'm taking this drug.'
- C. I should brush my teeth after every meal.'
- D. I will continue taking my birth control pills.'
Correct Answer: A
Rationale: Methotrexate can interact with certain vitamins (e.g., folic acid) if not prescribed, requiring medical guidance. The other statements align with safe methotrexate use.