Nokea
A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I can sleep on my side as long as I use a pillow between my legs.
- C. I will avoid bending at the waist to pick things up.
- D. I can bend down to tie my shoes after 2 weeks.
Correct Answer: D
Rationale: The correct answer is D because bending down to tie shoes after only 2 weeks post total hip replacement can put strain on the hip joint and increase the risk of dislocation. The client should avoid bending past 90 degrees to protect the new hip joint. Choices A, B, and C are all correct statements as they promote hip joint protection and reduce the risk of complications.
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During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?
- A. Dirty carpets requiring vacuuming
- B. Expired food found in the refrigerator
- C. Outdated medications stored in the kitchen
- D. Presence of multiple cats in the home
Correct Answer: B
Rationale: The correct answer is B (Expired food found in the refrigerator) because it poses a potential health risk to the client. Expired food can lead to foodborne illnesses, especially for an older adult post-surgery. Dirty carpets (choice A) may not directly impact the client's health. Outdated medications (choice C) can be addressed by the nurse without additional referrals. The presence of multiple cats (choice D) may be a concern for allergies or cleanliness, but it is not as urgent as expired food in terms of health risks.
Prior to a thoracentesis, what intervention should the nurse complete?
- A. Measure oxygen saturation before and after the procedure.
- B. Verify that the client has given informed consent.
- C. Explain the procedure briefly to the client and their family.
- D. Ensure informed consent has been obtained from the client.
Correct Answer: D
Rationale: The correct answer is D because ensuring informed consent is crucial before any invasive procedure to protect the client's autonomy and rights. This involves confirming the client's understanding of the procedure, risks, benefits, and alternatives. Option B is correct as it directly relates to the ethical and legal aspect of the procedure. Option A is incorrect as it focuses solely on monitoring oxygen saturation, which is important but not the priority before thoracentesis. Option C is incorrect as simply explaining the procedure does not ensure the client's understanding or consent.
A client had a hemicolectomy performed two days ago. Today, the nurse assessed the incision and discovered a small part of the abdominal viscera protruding through the incision. This complication of wound healing is known as:
- A. excoriation.
- B. dehiscence.
- C. decortication.
- D. evisceration.
Correct Answer: D
Rationale: Excoriation is an abrasion of the epidermis, or of any organ coating of the body, caused by trauma, chemicals, burns, or other causes. Dehiscence is a partial to complete separation of the wound edges with no abdominal tissue protrusion. Decortication is removal of the surface layer of an organ or structure, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. Evisceration occurs when the incision separates and the contents of the cavity spill out.
Mary Thomas presents with red, teary eyes, a runny nose, and a stuffy head. What nursing orders would be recommended?
- A. Antihistamines, aspirin, and cough syrup
- B. Increased fluids, steam inhalation, and rest
- C. Aspirin, cough syrup, and increased fluids
- D. Auscultation and percussion of the chest
Correct Answer: B
Rationale: Hydration, steam inhalation, and rest help alleviate symptoms and promote recovery.
What is the definition of blindness in terms of the best corrected visual acuity (BCVA)?
- A. Less than 20/200 even with correction
- B. Between 20/70 and 20/200 in the better eye with glasses
- C. 20/400 or greater with no light perception
- D. 20/40 in at least one eye with correction
Correct Answer: A
Rationale: Blindness is legally defined as BCVA less than 20/200 in the better eye with correction.