Nokea
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Use your incentive spirometer.
- B. Dangle your legs over the side of the bed.
- C. Perform regular isometric ejercicios.
- D. Increase your intake of protein.
Correct Answer: B
Rationale: Dangling legs allows gradual blood pressure adjustment, preventing orthostatic hypotension.
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A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. The best time to perform a breast self-examination is on the first day of my period.
- B. I can expect to have regular periods until I am in menopause.
- C. I might have headaches due to a decline in my estrogen levels.
- D. I should stop receiving Papanicolaou tests once I reach menopause.
Correct Answer: C
Rationale: Declining estrogen levels during perimenopause can cause headaches.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I should move my stronger leg forward before moving my weaker leg.
- C. I will move the cane forward 18 inches.
- D. I will hold the cane on my stronger side.
Correct Answer: B
Rationale: Moving the stronger leg first is correct for safe ambulation with a quad cane.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Postpone the procedure until the staff contacts the guardian.
- B. Obtain consent from the client.
- C. Request that the provider sign the consent form.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: In emergencies, implied consent allows life-saving procedures when delaying could harm the client.
A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Overweight
- B. Underweight
- C. Ideal body weight
- D. Obese
Correct Answer: A
Rationale: A BMI of 25-29.9 is categorized as 'overweight.' This indicates that the client is above the ideal weight range but has not reached the threshold for obesity.
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?
- A. I'll use focused breathing to control my pain.
- B. I'll learn to notice the sensation of muscle tension.
- C. I think about my grandfather's farm to reduce pain.
- D. I listen to my favorite music to take my mind off the pain.
Correct Answer: C
Rationale: Guided imagery involves visualizing a calming scene like a farm to distract from pain.