Nokea
A client with a total hip replacement asks about resuming sexual activity. Which response by the nurse is most appropriate?
- A. Wait at least 3 months post-surgery.'
- B. Avoid positions that flex the hip beyond 90 degrees.'
- C. Resume when you feel no pain.'
- D. Use a soft mattress for comfort.'
Correct Answer: B
Rationale: Avoiding excessive hip flexion prevents dislocation during sexual activity post-hip replacement.
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The nurse evaluates that the client correctly understands how to report signs and symptoms of bleeding when the client makes which of the following statements?
- A. Petechiae are large, red skin bruises.'
- B. Ecchymoses are large, purple skin bruises.'
- C. Emmum is an open cut on the skin.'
- D. Abrasions are small pinpoint red dots on the skin.'
Correct Answer: B
Rationale: Ecchymoses are large, purple bruises caused by bleeding under the skin, a common sign of thrombocytopenia. This statement shows correct understanding. Petechiae are small, pinpoint red dots, not large bruises; 'emmum' is not a medical term; and abrasions are superficial skin injuries, not bleeding signs.
The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?
- A. Assess the oral cavity each time mouth care is given and record observations.
- B. Use a soft toothbrush to brush the client's teeth after each meal.
- C. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours.
- D. Rinse the client's mouth with mouthwash several times a day.
Correct Answer: B
Rationale: Using a soft toothbrush after meals is an effective and safe method for providing oral hygiene, promoting cleanliness without causing trauma.
After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following?
- A. A developing infection.
- B. Bleeding in the operative site.
- C. Joint dislocation.
- D. Glue seepage into soft tissue.
Correct Answer: C
Rationale: Sudden pain and inability to move suggest joint dislocation, a surgical emergency.
The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan?
- A. Food intake
- B. Fluid volume
- C. Skin integrity
- D. Tissue perfusion
Correct Answer: D
Rationale: Post-AAA repair, tissue perfusion is critical to ensure graft patency and prevent ischemia in the lower extremities or organs. Teaching should emphasize signs of poor perfusion (e.g., pain, pallor, pulselessness) and follow-up care. Food, fluid, and skin integrity are less urgent.
The nurse is obtaining a blood sample for a PTT test ordered for a client who is taking heparin. It is 5 a.m. When drawing the blood, the nurse should do which of the following? Select all that apply.
- A. Awake the client
- B. Check the armband for client identification number and compare with the order
- C. Label the sample vial in front of the client
- D. Verify the room number with the room assignment
- E. Ask the client to state his/her name
Correct Answer: B,C,E
Rationale: Rationales: B) Checking the armband ensures correct client identification, critical for safety. C) Labeling the vial in front of the client prevents errors. E) Asking the client to state their name confirms identity. A) Awakening the client is unnecessary if asleep, as the draw can be done gently. D) Room number is unreliable for identification.