A client with a below-knee amputation is learning to wrap the residual limb. Which technique should the nurse teach?
- A. Wrap loosely to allow air circulation.
- B. Apply the wrap from proximal to distal.
- C. Use a figure-eight pattern.
- D. Secure the wrap with adhesive tape.
Correct Answer: C
Rationale: A figure-eight pattern ensures even pressure and proper shaping for prosthetic fitting.
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A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do?
- A. Put the tablet under the tongue until it is dissolved.
- B. Swallow the tablet with 120 mL of water.
- C. Chew the tablet until it is dissolved.
- D. Place the tablet between his cheek and gums.
Correct Answer: A
Rationale: Sublingual nitroglycerin is administered under the tongue for rapid absorption to relieve chest pain. Other methods (swallowing, chewing, or buccal placement) are incorrect for this medication.
The nurse teaches the client with a urinary diversion to attach the appliance to a standard urine collection bag at night. The most important reason for doing this is to prevent.
- A. Unlike reflux into the stoma.
- B. Appliance separation.
- C. Urine leakage.
- D. The need to restrict fluids.
Correct Answer: C
Rationale: A night collection bag prevents urine leakage by providing adequate capacity, reducing the risk of appliance overflow during sleep.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
- A. Hyperalbuminemia.
- B. Thrombocytopenia.
- C. Hypokalemia.
- D. Hypercalcemia.
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?
- A. Apples.
- B. Tomato juice.
- C. Whole wheat bread.
- D. Beef tenderloin.
Correct Answer: B
Rationale: Tomato juice is high in sodium, which should be limited on a 2-g sodium diet to prevent fluid retention in heart failure.
A client with acute renal failure has edema. The nurse should:
- A. Elevate the legs.
- B. Restrict fluids.
- C. Administer a diuretic.
- D. Increase sodium intake.
Correct Answer: B
Rationale: Fluid restriction helps manage edema in acute renal failure.
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