Nokea
A client who had a total knee replacement is to be discharged today. Which statement that the client makes indicates a need for further instruction?
- A. When I am walking, I will wear that ugly immobilizer.'
- B. I will sit with my leg elevated.'
- C. I think I understand how to use the continuous passive motion machine.'
- D. I won't put any weight at all on my affected leg.'
Correct Answer: D
Rationale: Total knee replacement typically allows partial weight-bearing with assistance post-surgery; complete non-weight-bearing suggests misunderstanding of mobility instructions.
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The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to
- A. Dress the child warmly to avoid chilling
- B. Keep the child away from other children for the duration of the rash
- C. Clean the affected areas with tepid water and detergent
- D. Wrap the child's hand in mittens or socks to prevent scratching
Correct Answer: D
Rationale: Wrap the child's hand in mittens or socks to prevent scratching. This prevents worsening of lesions and secondary infections.
The client with Cushing's disease will most likely exhibit signs of:
- A. Hypokalemia
- B. Hypernatremia
- C. Hypocalcaemia
- D. Hypermagnesemia
Correct Answer: A
Rationale: Cushing's disease causes hypercortisolism, leading to hypokalemia due to increased potassium excretion. Hypernatremia , hypocalcaemia , and hypermagnesemia are not typical in Cushing's disease.
The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider?
- A. I am tired of restricting fluids but know that I need to.
- B. I feel like I am beginning to get sick with a bad cold.
- C. I have been getting a lot of nasal pain with this spray.
- D. I have recently started to experience frequent headaches.
Correct Answer: D
Rationale: Frequent headaches (D) may indicate overmedication or hyponatremia, requiring urgent reporting. Fluid restriction (A), colds (B), and nasal pain (C) are less critical.
The practical nurse (PN) is assisting with a client who is undergoing labor induction with misoprostol. The PN notes late decelerations and minimal variability on the fetal heart rate monitor. After notifying the registered nurse, what should the PN do first?
- A. Administer 10 L/min oxygen by face mask
- B. Examine the perineum to check for bloody show
- C. Palpate the client's abdomen
- D. Reposition the client to a side-lying position
Correct Answer: D
Rationale: Repositioning to a side-lying position (D) improves placental perfusion, addressing late decelerations. Oxygen (A) may follow, but repositioning is first. Perineal exam (B) and palpation (C) are less urgent.
The nurse is caring for a 12-month-old client who is HIV-positive and severely immunosuppressed. Which of the following scheduled immunizations should the nurse anticipate administering to the client? Select all that apply.
- A. Haemophilus influenzae type b
- B. Hepatitis A
- C. Measles, mumps, rubella
- D. Pneumococcal conjugate vaccine
- E. Varicella
Correct Answer: A,D
Rationale: Hib (A) and PCV (D) are inactivated vaccines, safe for immunosuppressed children. MMR (C) and varicella (E) are live vaccines, contraindicated. Hepatitis A (B) is not routine at 12 months.