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A nurse is assessing a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Maintain abduction of the affected extremity.
- B. Position the client in high Fowler’s position.
- C. Encourage the client to cross their legs at the ankles.
- D. Have the client bend forward at the waist while sitting.
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. After a total hip arthroplasty, maintaining abduction of the affected extremity helps prevent dislocation of the hip prosthesis. This position helps stabilize the hip joint and reduces the risk of complications. Option B (Position the client in high Fowler's position) is incorrect as it does not directly address the postoperative care specific to a total hip arthroplasty. Option C (Encourage the client to cross their legs at the ankles) is incorrect because crossing legs can create pressure on the hip joint and increase the risk of dislocation. Option D (Have the client bend forward at the waist while sitting) is incorrect as this could also increase the risk of hip dislocation.
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A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemi The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?
- A. Determine the client's blood type.
- B. Avoid administering IV pain medication.
- C. Institute bleeding precautions.
- D. Implement airborne precautions.
Correct Answer: C
Rationale: The correct answer is C: Institute bleeding precautions. Petechiae are tiny red or purple spots on the skin caused by bleeding under the skin. In chronic lymphocytic leukemia, the client's platelet count may be low, leading to an increased risk of bleeding. By instituting bleeding precautions, the nurse can help prevent injuries that could result in further bleeding. Determining the client's blood type (A) is not necessary in this situation. Avoiding IV pain medication (B) is not directly related to managing petechiae. Implementing airborne precautions (D) is not relevant to the client's presentation with petechiae.
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for dietary consult. The client tells the nurse, 'I will have to eat whatever the dietitian tells me.' Which of the following statements by the nurse encourages the client's involvement in their plan of care?
- A. The dietitian will provide you with the best food choices to manage your diabetes.'
- B. I understand that the dietary choices can seem overwhelming.'
- C. I can assist you with making a list of foods you like for the dietitian.'
- D. Managing your diabetes will require you to make accommodations.'
Correct Answer: C
Rationale: The correct answer is C because it encourages the client's involvement in their plan of care by actively engaging them in the decision-making process. By offering to assist the client in making a list of foods they like for the dietitian, the nurse is promoting client autonomy and empowerment. This approach helps the client feel more in control of their dietary choices and encourages collaboration between the client, nurse, and dietitian.
Choice A is incorrect as it does not actively involve the client in decision-making. Choice B acknowledges the client's feelings but does not directly engage them in the process. Choice D focuses on the client's responsibilities but does not promote active participation.
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
- A. I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.'
- B. I rest in my recliner with my feet elevated for about an hour every afternoon.'
- C. I use my heating pad on a low setting to keep my feet warm.'
- D. I soak my feet in hot water before trimming my toenails.'
Correct Answer: A
Rationale: The correct answer is A because applying a lubricating lotion to the cracked areas on the soles of the feet helps prevent further skin breakdown and infection, which is crucial in peripheral arterial disease. Choice B may improve circulation, but it does not address foot care directly. Choice C can lead to burns or injury due to decreased sensation in peripheral arterial disease. Choice D poses a risk of injury or infection due to the potential for skin damage while soaking the feet. Overall, choice A is the most appropriate for maintaining foot health in peripheral arterial disease.
A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long-term glycemic control?
- A. Postprandial blood glucose level
- B. Glycosylated hemoglobin level
- C. Fasting blood glucose level
- D. Oral glucose tolerance test results
Correct Answer: B
Rationale: The correct answer is B: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. Monitoring glycosylated hemoglobin levels helps assess the effectiveness of the client's diabetes management plan over time.
A: Postprandial blood glucose level reflects short-term control after a meal.
C: Fasting blood glucose level reflects current blood glucose levels but not long-term control.
D: Oral glucose tolerance test results evaluate how the body handles glucose, not long-term control.
In summary, monitoring glycosylated hemoglobin levels is crucial for assessing long-term glycemic control in clients with diabetes.
A nurse is caring for a client who is experiencing an exacerbation of heart failure. Thenurse is
assessing the client 24 hr later. How should the nurse interpret the findings related to the
diagnosis of heart failure? For each finding, click to specify whe ther the finding is unrelated to
the diagnosis, a sign of potential improvement, or a sign of potential worsening condition. Diagnostic Results
Hgb 8.4 g/dL (12 to 18 g/dL)
Hct 42% (37% to 47%)
WBC count 9,800/mm3 (5,000 to 10,000/ mm3) Potassium 432
mEq/L (3.5 to 5 mEq/L)
- A. Lung sounds clean
- B. Creatinine 1.8 mm/dl
- C. Weight 113kg(249 lb)
- D. WBC Count 11,800mm3
- E. Temperature: 38.5°C (101.3°F)
- F. Shortness of breath with exertion
Correct Answer: A, B,C,D,E
Rationale:
The correct answer is A, B, C, D, E. In heart failure exacerbation, key indicators are related to fluid overload and organ perfusion. A) Lung sounds clean indicate potential improvement in pulmonary congestion. B) Creatinine 1.8 mm/dl is important for kidney function monitoring, as worsening kidney function can occur in heart failure. C) Weight 113kg reflects fluid retention, relevant for heart failure management. D) WBC count (11,800mm3) can indicate infection, which can worsen heart failure. E) Temperature 38.5°C can suggest infection or systemic inflammatory response, which worsens heart failure.