Nokea
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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The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate?
- A. A gelatin dessert.
- B. Yogurt.
- C. An orange.
- D. Peanuts.
Correct Answer: A
Rationale: Gelatin dessert is low in potassium, suitable for a client with hyperkalemia, unlike yogurt, oranges, or peanuts.
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.
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client?
- A. Keeping the client flat on one side or the other.
- B. Elevating the head of the bed to 30 degrees.
- C. Logrolling or turning as a unit when turning.
- D. Keeping the neck in a neutral position.
Correct Answer: A
Rationale: Keeping the client flat is contraindicated after a posterior fossa craniotomy, as it increases ICP. Elevating the head, logrolling, and neutral neck positioning promote venous drainage and spinal alignment, reducing ICP risk.
One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse encourages the client to:
- A. Apply heat to the extremity
- B. Elevate the legs above the heart
- C. Stop smoking
- D. Begin a jogging program
Correct Answer: C
Rationale: Stopping smoking promotes vasodilation by reducing nicotine-induced vasoconstriction and improving endothelial function, critical in arterial occlusive disease. Applying heat risks burns in ischemic tissue, elevating legs worsens arterial flow, and jogging may be contraindicated due to claudication.
Following a total hip replacement, the nurse should position the client in which of the following ways?
- A. Place weights alongside of the affected extremity to keep the extremity from rotating.
- B. Elevate both feet on two pillows.
- C. Keep the lower extremities adducted by use of an immobilization binder around both legs.
- D. Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs.
Correct Answer: D
Rationale: Slight abduction prevents dislocation by maintaining proper hip alignment.