Nokea
A client is learning about preventing hip dislocation before total hip arthroplasty. Which instruction should be included?
- A. Avoid bending the hip more than 90 degrees
- B. Avoid lying on the unaffected side
- C. Avoid crossing the legs at the knees
- D. Avoid keeping the legs in a neutral position
Correct Answer: C
Rationale: The correct instruction to prevent hip dislocation after total hip arthroplasty is to avoid crossing the legs at the knees. This position can put stress on the hip joint and increase the risk of dislocation. Choices A, B, and D are incorrect. Bending the hip more than 90 degrees, lying on the unaffected side, or keeping the legs in a neutral position are not directly related to preventing hip dislocation in this context.
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A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?
- A. Sit up for at least 30 minutes after eating
- B. Avoid fluids between meals
- C. Increase the intake of high-carbohydrate foods
- D. Avoid eating large meals that are high in simple sugars and liquids
Correct Answer: D
Rationale: The correct answer is D: 'Avoid eating large meals that are high in simple sugars and liquids.' Clients who have undergone partial gastrectomy are at risk of dumping syndrome, which can occur due to the rapid emptying of stomach contents into the small intestine. Consuming large meals high in simple sugars and liquids can exacerbate this syndrome, leading to symptoms like abdominal cramping and diarrhea. Choices A, B, and C are not directly related to preventing dumping syndrome and are not the priority concerns for a client post-partial gastrectomy.
A client with diabetes is being discharged. What is an essential teaching point?
- A. Monitor blood sugar levels once a week
- B. Instruct the client to administer insulin before meals
- C. Teach the client to exercise regularly to maintain glucose control
- D. Administer oral hypoglycemics as needed
Correct Answer: B
Rationale: Instructing the client to administer insulin before meals is a crucial teaching point for a client with diabetes. This action ensures proper glucose management by helping to control blood sugar levels. Monitoring blood sugar levels once a week (Choice A) may not be frequent enough to manage diabetes effectively. While regular exercise (Choice C) is beneficial for glucose control, the immediate administration of insulin is more critical at the time of discharge. Administering oral hypoglycemics as needed (Choice D) is inappropriate as it does not address the need for insulin administration for a client being discharged.
What is the proper technique for measuring blood pressure manually?
- A. Use a stethoscope to listen for the Korotkoff sounds
- B. Ensure the patient is seated with the arm supported
- C. Use a manual sphygmomanometer
- D. Deflate the cuff slowly while listening to the heartbeat
Correct Answer: A
Rationale: The correct technique for measuring blood pressure manually involves using a stethoscope to listen for the Korotkoff sounds. Choice B, ensuring the patient is seated with the arm supported, is important but not the specific technique for measuring blood pressure. Choice C, using a manual sphygmomanometer, is a necessary tool but not the technique itself. Choice D, deflating the cuff slowly while listening to the heartbeat, is not the correct technique as the deflation should be done while listening for the Korotkoff sounds to determine the systolic and diastolic blood pressure readings.
What is the correct intervention for a patient experiencing anaphylaxis?
- A. Administer epinephrine
- B. Provide oxygen
- C. Monitor airway
- D. All of the above
Correct Answer: D
Rationale: In cases of anaphylaxis, all of the listed interventions are crucial for effective management. Administering epinephrine is the primary treatment to reverse the allergic reaction rapidly. Providing oxygen ensures adequate oxygenation to vital organs, and monitoring the airway is essential to prevent obstruction and maintain a clear air passage. Therefore, all three interventions are necessary in managing anaphylaxis. Choices A, B, and C are not individually sufficient to address all aspects of anaphylaxis, making the comprehensive approach of 'All of the above' the correct answer.
A client is learning to use a cane due to left-leg weakness. Which instruction is correct?
- A. Use the cane on the stronger side of the body
- B. Maintain two points of support on the floor at all times
- C. Advance the cane and the strong leg together
- D. Advance the cane 30 to 45 cm with each step
Correct Answer: B
Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.