Nokea
A client with a spinal cord injury is at risk for pressure ulcers. Which nursing intervention is most effective?
- A. Reposition the client every 4 hours.
- B. Use a foam mattress without a cover.
- C. Apply lotion to bony prominences daily.
- D. Turn the client every 2 hours.
Correct Answer: D
Rationale: Turning every 2 hours redistributes pressure, preventing ulcer formation in immobilized clients.
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How often should the postoperative client's temperature be assessed during the first 24 hours after surgery?
- A. Every 2 hours.
- B. Every 4 hours.
- C. Every 6 hours.
- D. Every 8 hours.
Correct Answer: B
Rationale: Assessing temperature every 4 hours in the first 24 hours detects fever early, indicating potential infection or other complications.
A client with an ileal conduit asks how to reduce pouch odor. The nurse suggests:
- A. Avoiding broccoli.
- B. Using bleach to clean the pouch.
- C. Drinking less water.
- D. Applying powder to the stoma.
Correct Answer: A
Rationale: Odor-producing foods like broccoli should be avoided to minimize pouch odor.
Which of the following clinical manifestations does the nurse most likely observe in a client with Hodgkin's disease?
- A. Difficulty swallowing.
- B. Painless, enlarged cervical lymph nodes.
- C. Difficulty breathing.
- D. A feeling of fullness over the liver.
Correct Answer: B
Rationale: Hodgkin's disease typically presents with painless, enlarged cervical lymph nodes, often the first sign noticed. Difficulty swallowing, breathing, or liver fullness are less common or occur later.
A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following orders should the nurse question?
- A. Call for urine output <30 mL/hour for 2 consecutive hours.
- B. Metoprolol (Lopressor) 5 mg I.V. push.
- C. Symptom for a pulmonary artery catheter insertion.
- D. Titrate Dobutamine (Dobutrex) to keep systolic BP >100.
Correct Answer: B
Rationale: Metoprolol, a beta-blocker, can worsen cardiogenic shock by reducing heart rate and contractility. Other orders are appropriate for monitoring and supporting perfusion in cardiogenic shock.
Which of the following should the nurse interpret as an indication of a complication after the first few days of TPN therapy?
- A. Glycosuria.
- B. A 1- to 2-pound weight gain.
- C. Decreased appetite.
- D. Elevated temperature.
Correct Answer: D
Rationale: An elevated temperature after the first few days of TPN may indicate a complication like infection, particularly catheter-related. Glycosuria can occur with TPN but is managed, a small weight gain is expected, and decreased appetite is not a direct complication. CN: Pharmacological and parenteral therapies; CL: Analyze