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A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Monitor the client for weight.
- B. Check the client for increased hypopigmentation under the patch.
- C. Advise the client about increased dry mouth.
- D. Inform the client of the adverse effect of diarrhea.
Correct Answer: C
Rationale: Clonidine can cause dry mouth as a common side effect, and advising the client about this is appropriate for the plan of care.
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A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Each finding might support more than 1 disease process.
- A. Dyspnea
- B. Increased pain at incision site
- C. Tingling sensation to right foot
- D. Swelling at incision site
Correct Answer: A (fat embolism syndrome), B (acute compartment syndrome, infection), C (acute compartment syndrome), D (acute compartment syndrome, infection)
Rationale: Dyspnea is typical of fat embolism; increased pain and swelling suggest compartment syndrome or infection; tingling indicates compartment syndrome.
A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?
- A. Encourage socialization as a distractor when the client becomes agitated.
- B. Limit instructions to two steps at a time.
- C. Vary the staff providing care for the client
- D. Encourage independence in ADLs.
Correct Answer: B
Rationale: Limiting instructions to two steps accommodates cognitive decline in Alzheimer's, enhancing comprehension and reducing frustration.
A nurse is assisting with the care of an 18-year-old client who is at their provider's office for an annual physical. The client inquires about cancer examinations that they should have. Which of the following examinations should the nurse recommend?
- A. Testicular
- B. Skin
- C. Prostate
- D. Colorectal
Correct Answer: A
Rationale: Testicular self-examination is recommended for young males (e.g., 18-year-olds) to detect early signs of testicular cancer.
A nurse is reinforcing dietary teaching with a client who is postoperative and adheres to a vegetarian diet. Which of the following foods should the nurse recommend to the client as containing the highest amount of protein?
- A. Tomato soup
- B. Bananas
- C. Avocado
- D. Black beans
Correct Answer: D
Rationale: Black beans are a rich source of plant-based protein, making them the best recommendation for a vegetarian client needing protein post-surgery.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?
- A. Administer a glycerin suppository.
- B. Ambulate the client in the hallway.
- C. Request the client to be NPO.
- D. Offer an analgesic medication.
Correct Answer: B
Rationale: Ambulating the client first promotes bowel motility, addressing hypoactive bowel sounds and cramping, a common postoperative issue.