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A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation?
- A. Place a wedge pillow between the client's legs.
- B. Encourage the client to sit in a recliner.
- C. Allow the client to cross their legs when seated.
- D. Instruct the client to bend at the waist when picking up objects.
Correct Answer: A
Rationale: A wedge pillow maintains abduction, preventing hip dislocation. Recliners, leg crossing, or bending at the waist increase dislocation risk.
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A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?
- A. Place the client in a supine position.
- B. Ensure the device is kept below the level of the client's chest.
- C. Empty the collection chamber every 8 hr.
- D. Clamp the chest tube every 4 hr.
Correct Answer: B
Rationale: Keeping the drainage system below chest level ensures proper drainage and prevents backflow. Supine positioning may hinder drainage, routine emptying isn't needed, and clamping can interfere with suction.
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 montelukast. Which of the following statements should the nurse include?
- A. You should take this medication in the evening.
- B. You might experience weight gain while taking this medication.
- C. You need to limit your fluid intake while taking this medication.
- D. You can take this medication with an antacid.
Correct Answer: A
Rationale: Montelukast is taken in the evening for asthma control. Weight gain, fluid limits, or antacids aren't significant concerns.
A nurse is reinforcing teaching with a client who has a new prescription for bupropion. Which of the following statements should the nurse include?
- A. Take this medication at bedtime.
- B. You might have dry mouth while taking this medication.
- C. You need to avoid tyramine-rich foods.
- D. You can expect immediate mood improvement.
Correct Answer: B
Rationale: Bupropion can cause dry mouth, a side effect to monitor. It's taken in the morning, tyramine isn't a concern, and mood improvement takes weeks.
A nurse is caring for a client who has a new prescription for digoxin. Which of the following actions should the nurse take?
- A. Check the client's potassium level.
- B. Administer the medication with a high-fiber meal.
- C. Instruct the client to take the medication at bedtime.
- D. Monitor the client's blood pressure every 4 hr.
Correct Answer: A
Rationale: Digoxin toxicity risks increase with hypokalemia, so potassium monitoring is essential. Fiber meals, bedtime dosing, or routine blood pressure checks aren't specific.