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A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?
- A. Log roll the client and place adult disposable briefs beneath the client.
- B. Maintain traction while the client uses a urinal.
- C. Release the traction so the client can use a bedpan.
- D. Insert an indwelling urinary catheter preoperatively.
Correct Answer: B
Rationale: Maintaining traction while using a urinal preserves fracture alignment and stabilization, allowing safe and comfortable urination without compromising the injury.
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A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?
- A. Obtain a prostate-specific antigen blood level test.
- B. Take vitamin supplements.
- C. Increase physical activity.
- D. Consume a high protein diet.
Correct Answer: C
Rationale: Increasing physical activity helps maintain a healthy weight and improves pelvic blood flow, reducing BPH risk factors, unlike PSA testing, supplements, or high-protein diets, which lack direct preventive benefits.
The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?
- A. Provide the first medication prescribed for pain management.
- B. Review medical records to obtain pain tolerance expectations.
- C. Wait until the client is awake before providing pain management.
- D. Attempt to obtain a self-report of pain level from the client.
Correct Answer: A
Rationale: Providing the prescribed pain medication first prevents pain escalation in a sedated client, using behavioral indicators like vital signs to guide administration, as self-reporting may be unreliable.
A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing food intake, the nurse should include which type of fluid limitation?
- A. Overall fluid intake.
- B. Tea and hot chocolate.
- C. Low-sodium soups.
- D. Citrus fruit juices.
Correct Answer: B
Rationale: Limiting tea and hot chocolate reduces oxalate intake, which can contribute to calcium oxalate stone formation, a common type of urinary tract calculi.
A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
- A. Confirmation of the autoimmune disease process.
- B. Evidence of spread of the disease to the kidneys.
- C. Indication of the onset of joint degeneration.
- D. Representative of a decline in the client's condition.
Correct Answer: A
Rationale: Elevated rheumatoid factor is a marker of the autoimmune process in rheumatoid arthritis, confirming the diagnosis and indicating disease severity, not specific organ involvement or decline.
An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?
- A. Demonstrate the use of visual scanning during meals to the client and family.
- B. Explain that weight loss will be reversed after the acute phase of the stroke has ended.
- C. Suggest that the family bring foods from home that the client enjoys eating.
- D. Encourage the family to offer to feed the client when she does not eat her entire meal.
Correct Answer: A
Rationale: Teaching visual scanning compensates for visual perception deficits post-CVA, enabling the client to see all food on the tray, addressing the root cause of poor intake and improving nutrition.