Nokea
A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Encourage the client to flex the knee every 2 hr.
- B. Apply a continuous passive motion machine as prescribed.
- C. Instruct the client to keep the leg in a dependent position.
- D. Administer a diuretic to reduce swelling.
Correct Answer: B
Rationale: A CPM machine promotes mobility and prevents stiffness as prescribed. Flexion timing varies, dependent positioning increases swelling, and diuretics aren't routine.
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A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy. Which of the following statements should the nurse include?
- A. You will be given a sedative during the procedure.
- B. You can eat a light breakfast the morning of the procedure.
- C. You will need to maintain a clear liquid diet for 3 days prior to the procedure.
- D. You will need to take an antibiotic before the procedure.
Correct Answer: A
Rationale: A sedative is used to ensure comfort during a colonoscopy. Clear liquids are required only 1-2 days prior, no food is allowed the morning of, and antibiotics aren't standard.
A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz. of which of the following beverages contains the least amount of caffeine?
- A. Hot cocoa
- B. Cola soft drink
- C. Instant coffee
- D. Brewed green tea
Correct Answer: A
Rationale: Hot cocoa contains approximately 5 mg of caffeine per 240 mL, significantly less than cola soft drink (24-31 mg), instant coffee (57-96 mg), or brewed green tea (20-45 mg). Choosing hot cocoa helps reduce caffeine intake effectively.
A nurse is caring for a client who is postoperative following a hysterectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports mild vaginal bleeding.
- B. The client's temperature is 38.6°C (101.5°F).
- C. The client has not voided in 6 hr.
- D. The client's incision is intact with minimal drainage.
Correct Answer: B
Rationale: A temperature of 38.6°C suggests infection, requiring reporting. Mild bleeding, delayed voiding, and minimal drainage are expected or less urgent.
A nurse is reinforcing teaching with a client who has gout and a new prescription for allopurinol. Which of the following statements should the nurse include?
- A. You should limit your intake of vitamin C.
- B. You might experience a skin rash while taking this medication.
- C. You can take this medication with an antacid to reduce stomach upset.
- D. You should avoid drinking coffee while taking this medication.
Correct Answer: B
Rationale: Allopurinol can cause rashes, a potential sign of serious reactions. Vitamin C, antacids, or coffee don't significantly interact with allopurinol.
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.