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A client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which of the following activities should the nurse instruct the client to avoid?
- A. Crossing the legs while sitting down.
- B. Sitting on a raised commode seat.
- C. Using an abductor splint while lying on the side.
- D. Rising straight from a chair to a standing position.
Correct Answer: A
Rationale: Crossing the legs risks hip dislocation post-surgery.
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A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following should the nurse do?
- A. Remove all the food.
- B. Remove the coffee.
- C. Remove the toast, butter, and marmalade only.
- D. Substitute vegetable juice for the orange juice.
Correct Answer: B
Rationale: Coffee should be removed because caffeine can alter brain wave activity, affecting EEG results. The other foods do not typically interfere with the test.
The nurse is providing education to a client who is prescribed terbinafine for onychomycosis affecting the toenails. Which statements by the client demonstrate understanding regarding the teaching about terbinafine? Select all that apply.
- A. Following a successful course of treatment, my chance of getting cured is 90%.
- B. I will have to take terbinafine for 3 to 6 months.
- C. I will need liver function tests before starting terbinafine.
- D. I will take this on an empty stomach to help improve its absorption.
- E. It may cause taste or vision changes, so I will report vision changes to my doctor.
- F. Dark urine, pale stools, and persistent nausea may indicate a serious side effect.
Correct Answer: B,C,E
Rationale: Choice B is correct; terbinafine treatment for toenail onychomycosis typically lasts 3-6 months. Choice C is correct; liver function tests are required before and during treatment due to the risk of hepatotoxicity. Choice E is correct; terbinafine can cause taste or vision changes, and vision changes should be reported. Choice A is incorrect; the cure rate is approximately 70-80%, not 90%. Choice D is incorrect; terbinafine can be taken with or without food, and an empty stomach is not required. Choice F is correct; dark urine, pale stools, and nausea may indicate liver toxicity, a serious side effect.
An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?
- A. A woman who is 5 months pregnant with no apparent injuries.
- B. A middle-aged man with no injuries who has rapid respirations and coughs.
- C. A 10-year-old with a simple fracture of the humerus who is in severe pain.
- D. A 20-year-old with first-degree burns on her hands and forearms.
Correct Answer: B
Rationale: Rapid respirations and coughing suggest possible smoke inhalation, which can lead to airway compromise and requires urgent evaluation and transport.
Health maintenance and promotion activities are especially important for the older adult. Which of the following activities reflects the ability of chance activity for an otherwise healthy older adult?
- A. Drinks 1,500 mL of fluids per day.
- B. Consumes a balanced diet of 1,200 calories per day.
- C. Walks briskly for 10 minutes three times per week.
- D. Sleeps at least 8 hours each night.
Correct Answer: C
Rationale: Brisk walking promotes cardiovascular health and mobility. 1,500 mL fluid may be insufficient, 1,200 calories is too low for most, and 8 hours sleep is not activity-focused.