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A nurse is caring for 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 Fowlers 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. This is crucial post total hip arthroplasty to prevent dislocation. Abduction helps keep the hip joint stable and reduces the risk of the prosthesis slipping out of place. Choices B, C, and D are incorrect. High Fowler's position (B) is not necessary for this specific postoperative care. Crossing legs at the ankles (C) can lead to hip dislocation. Having the client bend forward at the waist (D) can also increase the risk of dislocation.
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A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect?
- A. Low urine specific gravity
- B. High urine specific gravity
- C. Elevated potassium levels
- D. Decreased potassium levels
Correct Answer: A
Rationale: The correct answer is A: Low urine specific gravity. Excessive diuretic use can lead to volume depletion and low sodium levels. Low sodium levels cause the kidneys to excrete more water, resulting in dilute urine with low specific gravity. High urine specific gravity would indicate concentrated urine, which is not expected in this situation. Elevated potassium levels (choice C) are not typically associated with overuse of diuretics, as diuretics can actually lead to potassium loss. Similarly, decreased potassium levels (choice D) are commonly seen with diuretic use due to increased excretion of potassium by the kidneys.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, the lungs are unable to eliminate enough carbon dioxide, leading to an increase in CO2 levels in the blood, causing acidosis. This is due to inadequate ventilation or impaired gas exchange. The other options are incorrect because: B) Loss of bicarbonate is seen in metabolic acidosis, not respiratory acidosis. C) Excessive vomiting leads to metabolic alkalosis, not respiratory acidosis. D) Hyperventilation would actually correct respiratory acidosis by decreasing CO2 levels.
A nurse is providing teaching to a client who has a new prescription for cephalexin oral suspension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will keep the medication refrigerated.
- B. I will mix the medication with juice before taking it.
- C. I will stop taking the medication when I feel better.
- D. I will take the medication on an empty stomach.
Correct Answer: A
Rationale: The correct answer is A: "I will keep the medication refrigerated." This is correct because cephalexin oral suspension should be stored in the refrigerator to maintain its potency and stability. Storing it at room temperature may lead to degradation of the medication. Choice B is incorrect as cephalexin should be taken as prescribed, not mixed with juice. Choice C is incorrect as the full course of antibiotics should be completed even if the client feels better. Choice D is incorrect as cephalexin can be taken with or without food.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. This finding indicates an air leak in the system, which can compromise the client's respiratory status. The continuous bubbling signifies that air is escaping through the chest tube rather than being properly drained. The nurse should report this to the provider immediately for further evaluation and intervention to prevent pneumothorax or other complications.
The other choices (B, C, D) are incorrect because intermittent bubbling in the suction chamber is expected as it indicates proper functioning of the system. Clear drainage of 50 mL over 8 hours is within normal limits and does not pose an immediate threat to the client. Mild pain at the insertion site is also a common finding after chest tube insertion and does not require urgent intervention unless it worsens or is accompanied by other concerning symptoms.
A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will eat a high-protein diet before exercise.
- B. I will check my blood sugar level before exercising.
- C. I will avoid all forms of sugar.
- D. I will only take my insulin when I feel symptoms of high blood sugar.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Checking blood sugar before exercise is crucial for individuals with type 1 diabetes to prevent hypoglycemia.
2. It allows the client to adjust their insulin dosage or carbohydrate intake based on their blood sugar level.
3. Monitoring blood sugar helps maintain safe levels during physical activity.
4. Other choices are incorrect as high-protein diet may not be necessary, avoiding all sugar is extreme, and insulin should be taken as prescribed, not based on symptoms.