Nokea
A client with type 2 diabetes mellitus presents to the clinic with a foot ulcer. Which instruction should the nurse provide to the client to promote healing of the ulcer?
- A. Apply a heating pad to the ulcer twice daily.
- B. Wear tight-fitting shoes to protect the ulcer.
- C. Keep the ulcer clean and dry.
- D. Limit walking to reduce pressure on the ulcer.
Correct Answer: C
Rationale: The correct answer is C: Keep the ulcer clean and dry. This instruction is essential for promoting healing of the foot ulcer in a client with type 2 diabetes mellitus. Keeping the ulcer clean helps prevent infection, while keeping it dry promotes a better environment for healing.
A: Applying a heating pad can increase the risk of burns and should be avoided.
B: Wearing tight-fitting shoes can cause further damage and hinder healing.
D: Limiting walking may reduce pressure on the ulcer, but mobility is important for circulation and overall health. Keeping the ulcer clean and dry is the most critical instruction.
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A healthcare professional is assessing a client with severe dehydration. Which finding indicates a need for immediate intervention?
- A. Heart rate of 110 beats per minute.
- B. Blood pressure of 90/60 mm Hg.
- C. Urine output of 20 ml/hour.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: The correct answer is C: Urine output of 20 ml/hour. In severe dehydration, decreased urine output indicates compromised renal function and impaired fluid balance, necessitating immediate intervention to prevent further complications. A: Heart rate of 110 bpm is elevated but not an immediate concern. B: Blood pressure of 90/60 mm Hg is low but may be compensated in dehydration. D: Dry mucous membranes are a sign of dehydration but not an immediate threat compared to inadequate urine output.
A client with Parkinson's disease is being cared for by a nurse. Which intervention should be included to address the client's bradykinesia?
- A. Encourage daily walking.
- B. Provide thickened liquids to prevent aspiration.
- C. Offer small, frequent meals.
- D. Teach the client to use adaptive utensils.
Correct Answer: A
Rationale: The correct answer is A: Encourage daily walking. Bradykinesia in Parkinson's disease refers to slowness of movement. Walking helps improve coordination, balance, and overall mobility in clients with Parkinson's. It promotes muscle strength and flexibility, counteracting the effects of bradykinesia. Walking also stimulates dopamine release, which is reduced in Parkinson's. Choice B is incorrect as thickened liquids are for dysphagia, not bradykinesia. Choice C is incorrect as meal frequency does not directly address bradykinesia. Choice D is incorrect as adaptive utensils help with fine motor skills, not slowness of movement.
A client with heart failure is receiving digoxin (Lanoxin). Which finding indicates that the medication is effective?
- A. Increased heart rate.
- B. Decreased pedal edema.
- C. Elevated blood pressure.
- D. Improved urine output.
Correct Answer: B
Rationale: The correct answer is B: Decreased pedal edema. Digoxin is a medication commonly used to treat heart failure by improving the heart's ability to pump effectively. As the medication helps to reduce fluid buildup in the body, a decrease in pedal edema (swelling in the feet and ankles) indicates that digoxin is effectively managing the client's heart failure. Increased heart rate (A) may indicate digoxin toxicity, elevated blood pressure (C) is not a typical indicator of digoxin effectiveness, and improved urine output (D) may be a result of diuretic therapy rather than specifically digoxin efficacy in heart failure management.
During the initial assessment of a client with a history of substance abuse admitted for detoxification, which intervention is most important?
- A. Obtain a detailed substance use history.
- B. Establish a trusting nurse-client relationship.
- C. Evaluate the client's physical health status.
- D. Determine the client's readiness for change.
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's physical health status. This is crucial during detoxification as substance withdrawal can lead to serious physical health complications such as seizures or cardiac issues. Assessing physical health status allows for prompt intervention if needed. Obtaining a detailed substance use history (A) can provide valuable information but is not immediate priority during initial assessment. Establishing a trusting nurse-client relationship (B) is important but ensuring physical safety comes first. Determining client's readiness for change (D) is important for long-term treatment planning but not as urgent as assessing physical health status.
A client with chronic renal failure is prescribed epoetin alfa (Epogen). Which outcome indicates that the medication is effective?
- A. Increased urine output.
- B. Decreased blood pressure.
- C. Improved hemoglobin levels.
- D. Stable potassium levels.
Correct Answer: C
Rationale: The correct answer is C: Improved hemoglobin levels. Epoetin alfa is a medication used to treat anemia in patients with chronic renal failure by stimulating red blood cell production. Improved hemoglobin levels indicate that the medication is effective in addressing the anemia associated with renal failure. Increased urine output (A) is not a direct outcome of epoetin alfa therapy. Decreased blood pressure (B) and stable potassium levels (D) are not specific indicators of the medication's effectiveness in treating anemia.