Nokea
A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?
- A. Avoid crossing your legs at the knees or ankles.
- B. Do not sleep on the side of the hip that was operated on.
- C. Sit in high chairs and keep your knees higher than your hips.
- D. Do not bend forward at the waist to pick up objects.
Correct Answer: A
Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.
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A client is post-operative day one following an open cholecystectomy. The nurse notices the client's drainage from the T-tube is dark green. What is the most appropriate action for the nurse to take?
- A. Document the finding as normal.
- B. Notify the healthcare provider immediately.
- C. Decrease the suction on the T-tube.
- D. Flush the T-tube with saline to ensure patency.
Correct Answer: A
Rationale: Dark green drainage from a T-tube after a cholecystectomy is bile, which is an expected finding. Bile is normally dark green in color. It is important for the nurse to recognize this as a normal post-operative occurrence and document the finding. There is no need to notify the healthcare provider immediately as this finding is an anticipated part of the client's recovery. Decreasing the suction on the T-tube or flushing it with saline is unnecessary and may not be indicated based on the color of the drainage. Therefore, the most appropriate action for the nurse to take is to document the dark green drainage as a normal finding.
A dispersion consists of a solute dispersed through a dispersing vehicle. Which of the following dispersions is a liquid for topical application that contains insoluble solids or liquids?
- A. Ointment
- B. Lotion
- C. Paste
- D. Gel
Correct Answer: B
Rationale: The correct answer is B, 'Lotion.' A lotion is a liquid dispersion that contains insoluble solids or liquids for topical application. Ointments are more semi-solid and occlusive, pastes are thicker and contain higher concentrations of solids, and gels have a jelly-like consistency due to their three-dimensional network structure. Therefore, among the options, a lotion is the most suitable choice for containing insoluble solids or liquids for topical application.
After admission, which observation is most important for the nurse to report immediately for an adult client who weighs 150 pounds and has partial-thickness and full-thickness burns over 40% of the body from a house fire?
- A. Poor appetite and refusal to eat
- B. Systolic blood pressure at 102
- C. Painful moaning and crying
- D. Urinary output of 20 ml/hr
Correct Answer: D
Rationale: A urinary output of 20 ml/hr is a sign of inadequate kidney perfusion and could indicate hypovolemic shock, which requires immediate intervention. In this situation, with severe burns over a large portion of the body, monitoring urinary output is crucial to assess kidney function and fluid status. Poor appetite, systolic blood pressure at 102, and painful moaning and crying are important but do not indicate the immediate need for intervention like inadequate urinary output does.
A client post-thoracotomy is complaining of severe pain with deep breathing and coughing. What should the nurse encourage the client to do to manage the pain and prevent respiratory complications?
- A. Hold a pillow against the chest while coughing (splinting).
- B. Take shallow breaths to avoid pain.
- C. Increase the dose of pain medication.
- D. Avoid deep breathing exercises.
Correct Answer: A
Rationale: Splinting the chest with a pillow helps manage pain during deep breathing and coughing, which is essential to prevent respiratory complications such as atelectasis or pneumonia after thoracic surgery. Holding a pillow against the chest while coughing (splinting) supports the incision site and reduces the pain associated with deep breathing and coughing. Encouraging shallow breaths (Choice B) can lead to respiratory complications due to inadequate lung expansion. Increasing pain medication (Choice C) should be done based on healthcare provider orders and not solely for this situation. Avoiding deep breathing exercises (Choice D) can worsen respiratory function and increase the risk of complications.
Which of the following dietary modifications should be recommended for a patient with chronic kidney disease (CKD)?
- A. High protein, low sodium
- B. Low protein, high potassium
- C. Low sodium, low potassium
- D. High calcium, low phosphorus
Correct Answer: C
Rationale: A low sodium, low potassium diet is often recommended for patients with CKD to manage fluid balance and prevent electrolyte imbalances that the kidneys can no longer regulate effectively. High protein diets, as mentioned in choice A, can put extra strain on the kidneys, making it an incorrect choice. Choice B, which suggests a low protein, high potassium diet, is also incorrect because high potassium levels can be harmful to individuals with CKD. Choice D, advocating for a high calcium, low phosphorus diet, is not the typical dietary recommendation for CKD patients, even though managing calcium and phosphorus levels is important in their diet.