Nokea
A nurse is caring for a client who is postoperative following a hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
- A. Place a pillow between the client's legs.
- B. Place the client in a high Fowler's position.
- C. Maintain the client in a side-lying position.
- D. Keep the client's legs elevated.
Correct Answer: A
Rationale: Placing a pillow between the client's legs is the correct action to prevent dislocation of the prosthesis after hip arthroplasty. This positioning helps maintain proper alignment and stability of the hip joint, reducing the risk of dislocation. Placing the client in a high Fowler's position (choice B) is not recommended after hip arthroplasty as it may strain the hip joint. Maintaining the client in a side-lying position (choice C) or keeping the client's legs elevated (choice D) does not provide the same level of support and alignment as placing a pillow between the legs.
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A nurse is reviewing the medical record of a client who is at 30 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 140/90 mm Hg
- B. 1+ pitting edema in the lower extremities
- C. Weight gain of 2.3 kg (5 lb) in 1 week
- D. Mild headache
Correct Answer: C
Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening preeclampsia due to fluid retention, which can lead to serious complications. This finding should be reported promptly to the provider for further assessment and intervention. Blood pressure of 140/90 mm Hg is high but may not be an immediate concern for a client with preeclampsia at 30 weeks. 1+ pitting edema in the lower extremities is common in pregnancy, especially in the third trimester, and may not be a significant finding in isolation. A mild headache can be a common symptom in pregnancy and may not be indicative of worsening preeclampsia unless accompanied by other concerning signs.
A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include?
- A. Resume a regular diet immediately.
- B. Remove the adhesive bandage after 3 days.
- C. Begin moderate activity immediately.
- D. Take a tub bath instead of a shower.
Correct Answer: B
Rationale: The correct answer is B. The adhesive bandage should be removed 3 days after a laparoscopic cholecystectomy to allow the incision to heal properly. Choice A is incorrect as the client should start with a clear liquid diet and advance to a regular diet as tolerated. Choice C is incorrect because the client should gradually increase activity levels as tolerated. Choice D is incorrect as the client should avoid tub baths and opt for showers to prevent infection and promote healing.
Which electrolyte imbalance is a common concern in patients receiving loop diuretics?
- A. Hyperkalemia
- B. Hyponatremia
- C. Hypokalemia
- D. Hypercalcemia
Correct Answer: C
Rationale: The correct answer is Hypokalemia (Choice C). Loop diuretics can lead to potassium loss in the urine, resulting in hypokalemia. This electrolyte imbalance is a common concern with loop diuretic therapy and necessitates regular monitoring. Hyperkalemia (Choice A) is not typically associated with loop diuretics but with conditions like renal failure. Hyponatremia (Choice B) is more common with thiazide diuretics. Hypercalcemia (Choice D) is not a typical concern with loop diuretic use.
What is the appropriate intervention when a patient experiences a fall?
- A. Assess for injuries
- B. Call for help
- C. Document the fall
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The appropriate intervention when a patient experiences a fall is to assess for injuries. This immediate action helps in identifying any harm or complications resulting from the fall, allowing for timely intervention. Calling for help may be necessary after assessing the injuries, but the priority is to evaluate the patient's condition. Documenting the fall is important for record-keeping purposes but should come after ensuring the patient's safety. Notifying the healthcare provider can be done once the assessment has been completed and any necessary initial interventions have been initiated.
What is the priority nursing action for a patient with shortness of breath?
- A. Administer oxygen
- B. Reposition the patient
- C. Check oxygen saturation
- D. Elevate the head of the bed
Correct Answer: A
Rationale: Administering oxygen is the priority nursing action for a patient experiencing shortness of breath. Oxygen therapy aims to improve oxygenation levels quickly, addressing the underlying cause of the symptom. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in this scenario to ensure adequate oxygen supply to the body.