Nokea
A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?
- A. Abduction.
- B. Internal rotation.
- C. External rotation.
- D. Adduction.
Correct Answer: A
Rationale: Abduction prevents hip dislocation by keeping the leg away from the midline, maintaining joint stability post-arthroplasty.
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A nurse is preparing a client for intradermal tuberculin skin testing (TST). Which of the following statements should the nurse make?
- A. An indurated area of 4 millimeters indicates a positive result.
- B. The injection site will be evaluated within 24 hours.
- C. A positive result does not always indicate active disease.
- D. The test will not be administered if you have had a previous negative result.
Correct Answer: C
Rationale: A positive tuberculin skin test result indicates TB infection but does not necessarily mean active disease, requiring further testing to confirm.
A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?
- A. Place a sandbag to the lateral calf.
- B. Place a wedge pillow between the legs.
- C. Place a trochanter roll against the thigh.
- D. Place a footboard on the bed.
Correct Answer: B
Rationale: Placing a wedge pillow between the legs maintains hip abduction, preventing adduction and reducing the risk of dislocation after hip arthroplasty.
A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching?
- A. The medication causes amenorrhea if taken along with an oral contraceptive.
- B. You should wear glasses instead of contacts while taking this medication.
- C. A yellow tint to the skin is an expected reaction to the medication.
- D. Lifelong treatment with this medication is necessary.
Correct Answer: B
Rationale: Rifampin can cause discoloration of body fluids, including tears, which can stain contact lenses. Therefore, it is recommended to wear glasses instead of contacts while taking this medication.
A nurse is phoning a provider to report a client's serum potassium of 6.2 mEq/L. Which of the following medications should the nurse expect the provider to prescribe?
- A. Potassium iodide.
- B. Lactulose.
- C. Sodium polystyrene sulfonate.
- D. Acetylcysteine.
Correct Answer: C
Rationale: Sodium polystyrene sulfonate is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, lowering serum potassium levels.
A nurse is providing care for an older adult client who has hyperglycemia, polydipsia, and polyuria. Which of the following manifestations supports the clinical presentation of hyperosmolar hyperglycemic syndrome (HHS)? (Select All that Apply.)
- A. Acetone breath.
- B. Fever.
- C. Serum glucose 800 mg/dL (74 to 106 mg/dL).
- D. Serum bicarbonate 15 mEq/L (21 to 28 mEq/L).
- E. Insidious onset.
Correct Answer: B,C,E
Rationale: Fever, serum glucose of 800 mg/dL, and insidious onset are characteristic of HHS, often triggered by infection and marked by extreme hyperglycemia without significant ketoacidosis.