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A nurse is caring for a client who is postoperative following a hip replacement. Which of the following actions should the nurse take?
- A. Place an abduction pillow between the client's legs.
- B. Instruct the client to bend at the hip when sitting.
- C. Apply a warm compress to the surgical site.
- D. Encourage the client to cross their legs when seated.
Correct Answer: A
Rationale: An abduction pillow prevents dislocation by maintaining hip alignment. Bending, warm compresses, and leg crossing increase dislocation risk.
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A nurse is reinforcing teaching with a client who has a new prescription for insulin glargine. Which of the following instructions should the nurse include?
- A. Take this insulin with meals.
- B. You might gain weight while taking this insulin.
- C. Shake the vial before drawing up the insulin.
- D. Use this insulin only when your blood sugar is high.
Correct Answer: B
Rationale: Insulin glargine can cause weight gain, a side effect to monitor. It's taken daily, not with meals, shaking is avoided, and it's not for acute highs.
A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
- A. Weight loss
- B. Decreased blood pressure
- C. Decreased skin turgor
- D. Crackles heard in the lungs
Correct Answer: D
Rationale: Crackles in the lungs indicate pulmonary edema from fluid overload. Weight loss, low blood pressure, or poor skin turgor suggest dehydration, not overload.
A nurse is reinforcing teaching with a client who has a new prescription for doxycycline. Which of the following instructions should the nurse include?
- A. Take this medication with an antacid.
- B. You might need to wear sunscreen while taking this medication.
- C. You need to refrigerate this medication.
- D. You should stop taking this medication if you feel better.
Correct Answer: B
Rationale: Doxycycline increases photosensitivity, requiring sunscreen. Antacids reduce absorption, refrigeration isn't needed, and stopping early risks resistance.
A nurse is reinforcing teaching about laboratory testing with a client. Which of the following findings should the nurse include as an indicator of infection?
- A. Decreased platelets
- B. Increased iron level
- C. Increased erythrocyte sedimentation rate
- D. Decreased hemoglobin
Correct Answer: C
Rationale: Increased ESR indicates inflammation, often due to infection. Platelet or hemoglobin decreases or iron increases aren't specific to infection.
A nurse is reinforcing discharge teaching with the caregiver of a client who has a dependent personality disorder. Which of the following instructions should the nurse include in the teaching?
- A. Limit the client's social interactions.
- B. Encourage the client to be assertive.
- C. Assume responsibility for making the client's decisions.
- D. Maintain a verbal no-harm contract with the client.
Correct Answer: B
Rationale: Encouraging assertiveness promotes independence, countering dependency tendencies. Limiting interactions or making decisions for the client reinforces dependence, and no-harm contracts are unrelated.