Nokea
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client states that his legs are numb all the way up to his hips. The nurse should do which of the following next? Select all that apply.
- A. Call his family to come in to visit with him.
- B. Notify his health care provider of the change.
- C. Place respiratory resuscitation equipment in the client's room.
- D. Check for advancing levels of paresthesia.
- E. Perform ankle pumps to increase circulation and relieve numbness.
Correct Answer: B,C,D
Rationale: Rapidly progressing numbness suggests a neurological condition like Guillain-Barré syndrome, requiring immediate provider notification (B), monitoring for respiratory involvement with resuscitation equipment (C), and ongoing assessment of paresthesia (D). Family visits and ankle pumps are not priorities.
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The client scheduled for a transurethral resection prostatectomy (TURP) asks the nurse to explain how the prostate is going to be removed. The nurse should tell the client that the prostate will be removed through which pathway?
- A. The urethra
- B. A lower abdominal incision
- C. An upper abdominal incision
- D. An incision made in the perineal area
Correct Answer: A
Rationale: A TURP is done through the urethra. An instrument called a resectoscope is used to remove the tissue using high-frequency current. A lower abdominal incision is used for suprapubic or retropubic prostatectomy. An upper abdominal incision is not used. An incision between the scrotum and anus is made when a perineal prostatectomy is performed.
The nurse-manager on the medical unit is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply.
- A. Admission to the hospital.
- B. Transfer to the nursing home.
- C. Transfer of a client from surgery to the surgical unit.
- D. Admission to a home health agency from the hospital.
- E. Move from a double room to a single room on the same unit.
Correct Answer: A,B,C,D
Rationale: Medication reconciliation is required during transitions of care (admission, transfers, discharge to home health) to ensure accuracy. Moving rooms on the same unit does not typically require reconciliation.
The infusion rate of total parenteral nutrition is tapered before being discontinued. This is done to prevent which of the following complications?
- A. Essential fatty acid deficiency.
- B. Dehydration.
- C. Rebound hypoglycemia.
- D. Malnutrition.
Correct Answer: C
Rationale: Tapering TPN prevents rebound hypoglycemia by allowing the body to adjust to reduced glucose infusion.
A postoperative client is prescribed incentive spirometry. What is the primary purpose of this intervention?
- A. Prevent atelectasis.
- B. Reduce incisional pain.
- C. Improve circulation.
- D. Promote wound healing.
Correct Answer: A
Rationale: Incentive spirometry encourages deep breathing to expand alveoli, preventing atelectasis after surgery.
A client with Parkinson's disease is prescribed levodopa-carbidopa (Sinemet). The nurse should instruct the client to:
- A. Take the medication on an empty stomach.
- B. Avoid vitamin B6 supplements.
- C. Take the medication with a high-protein meal.
- D. Stop the medication if dizziness occurs.
Correct Answer: B
Rationale: Vitamin B6 can reduce the effectiveness of levodopa, so clients should avoid B6 supplements.