Nokea
A client with a hip fracture is scheduled for surgery. Which preoperative teaching should the nurse include?
- A. Avoid coughing post-surgery
- B. Expect to ambulate immediately
- C. Use of incentive spirometry
- D. Limit fluid intake
Correct Answer: C
Rationale: Incentive spirometry prevents postoperative pulmonary complications like atelectasis, critical for a client with limited mobility post-hip surgery.
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A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has $300 \mathrm{~mL}$ of solution left. The nurse should:
- A. Continue the infusion until the remaining 300mL is infused
- B. Change the filter on the tubing and continue with the infusion
- C. Notify the physician and obtain orders to alter the rate of the solution
- D. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution
Correct Answer: D
Rationale: TPN solutions should not hang for more than 24 hours due to infection risk. The nurse should discontinue the current bag, change the tubing, and hang a new bag. Continuing or altering the rate is unsafe.
On the first postpartum day, the nurse is caring for a primiparous client who has recently emigrated from Japan to the United States and speaks only a little English. The nurse observes that the client has been bottle-feeding her neonate on occasion, but most of the neonatal care is being performed by the client's mother-in-law. Which of the following actions would be most appropriate?
- A. Notify the social worker because bonding may be affected.
- B. Document the unusual maternal behavior in the client's chart.
- C. Determine whether this is a cultural practice for the client and her family.
- D. Obtain an order to make a home visit after the client's discharge.
Correct Answer: C
Rationale: Assessing whether the mother-in-law's involvement is a cultural practice respects the client's background and avoids misjudging normal family dynamics.
The physician orders I.V. cefazolin (Kefzol) 1g for a client. In preparing to administer the Kefzol, the nurse notes that the client is allergic to penicillin. Based on this information, what is an appropriate action for the nurse to take?
- A. Continue to prepare to administer the Kefzol as ordered
- B. Notify the physician of the client's allergy to penicillin
- C. Administer the Kefzol, staying at the client's bedside during the infusion
- D. Call the pharmacist to verify that the Kefzol should be administered as ordered
Correct Answer: B
Rationale: Cefazolin, a cephalosporin, has a risk of cross-reactivity in penicillin-allergic clients, so the nurse should notify the physician to consider an alternative. Administering or verifying with the pharmacist without physician consultation is unsafe.
The nursing staff has safely and successfully secluded and restrained a client with acute mania who discussed the nurse and threw a chair against the wall in the community room. Which statement by the nurse is most helpful to the client at this time?
- A. Threatening others and throwing furniture is not allowed.'
- B. You have been restrained until you can manage your behavior.'
- C. Since you have been here before, you know what the rules are.'
- D. We are only doing this for your own good, so calm down.'
Correct Answer: B
Rationale: Explaining the reason for restraint (to ensure safety until behavior is managed) is therapeutic, clear, and nonjudgmental, helping the client understand the intervention.
The clinic nurse is reviewing the laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following laboratory findings indicates that the allopurinol is having the desired effect?
- A. Decreased serum uric acid level.
- B. Decreased serum potassium level.
- C. Increased serum calcium level.
- D. Increased hemoglobin level.
Correct Answer: A
Rationale: Allopurinol reduces serum uric acid levels by inhibiting xanthine oxidase, which is its therapeutic effect in treating gout.