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A nurse is caring for a client who is postoperative following a mastectomy. Which of the following actions should the nurse take?
- A. Encourage the client to perform arm exercises on the affected side.
- B. Instruct the client to keep the affected arm dependent.
- C. Apply a cold pack to the surgical site every 2 hr.
- D. Administer a diuretic to reduce arm swelling.
Correct Answer: A
Rationale: Arm exercises prevent lymphedema and promote mobility. Dependent positioning worsens swelling, cold packs aren't standard, and diuretics aren't routine.
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A nurse is caring for a client who is postoperative following a cesarean birth. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate within 24 hr.
- B. Instruct the client to avoid coughing.
- C. Apply a cold pack to the incision site.
- D. Administer a laxative every 2 hr.
Correct Answer: A
Rationale: Ambulation within 24 hours prevents thromboembolism and aids recovery. Coughing supports lung function, cold packs aren't standard, and laxatives aren't given that frequently.
A nurse is caring for a client who is postoperative following a lumbar puncture. Which of the following actions should the nurse take?
- A. Encourage the client to lie flat for 2 to 4 hr.
- B. Instruct the client to limit fluid intake.
- C. Apply a warm compress to the puncture site.
- D. Monitor the client's temperature every 8 hr.
Correct Answer: A
Rationale: Lying flat prevents post-lumbar puncture headache by reducing CSF leakage. Fluid restriction is unnecessary, warm compresses aren't standard, and temperature checks are more frequent if infection is suspected.
A nurse is reinforcing teaching with a client who has a new prescription for valsartan. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with a high-potassium meal.
- B. I might need to check my blood pressure regularly.
- C. I need to avoid exercise.
- D. I can stop taking this medication if I feel better.
Correct Answer: B
Rationale: Valsartan requires blood pressure monitoring, showing understanding. Potassium meals, exercise avoidance, and stopping abruptly aren't appropriate.
A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following statements should the nurse include in the teaching?
- A. You might experience weight loss while taking this medication.
- B. You should expect to have increased energy within a few days.
- C. You might feel drowsy, so avoid driving until you know how this medication affects you.
- D. You can stop taking this medication as soon as your symptoms improve.
Correct Answer: C
Rationale: Amitriptyline can cause drowsiness, so avoiding driving is prudent. Weight gain, not loss, is common, effects take weeks, and abrupt stopping risks relapse.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
- A. Suction the tube every 2 hr.
- B. Secure the tube to the client's face.
- C. Monitor the client's cuff pressure daily.
- D. Reposition the client every 4 hr.
Correct Answer: B
Rationale: Securing the tube prevents dislodgement, ensuring airway safety. Suctioning is as needed, cuff pressure checks are frequent, and repositioning is every 2 hours.