Nokea
A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?
- A. Position the lower extremities so that they are touching.
- B. Ensure that the client's heels are touching the bed.
- C. Instruct the client to avoid movement of the affected leg.
- D. Prevent hip flexion of the affected extremity.
Correct Answer: D
Rationale: Preventing hip flexion of the affected extremity is correct because excessive hip flexion can increase the risk of dislocation after a total hip arthroplasty.
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A nurse is preparing to administer 0.9% sodium chloride IV infusion 1000 mL bag at a rate of 200 mL/hr for a client who has rhabdomyolysis. The nurse should expect the IV pump to infuse over how many hours? (Round the answer to the nearest whole number. (Use a leading zero if it applies. Do not use a trailing zero))
- A. 5 hours
- B. 4 hours
- C. 6 hours
- D. 7 hours
Correct Answer: A
Rationale: 1000 mL ÷ 200 mL/hr = 5 hours. The infusion will take 5 hours.
A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following risk factors should the nurse identify as contributing to this diagnosis?
- A. High-purine diet.
- B. Low levels of serum calcium.
- C. Female gender.
- D. Drinking large quantities of fluids.
Correct Answer: A
Rationale: A high-purine diet increases uric acid, forming crystals and stones, contributing to urolithiasis.
A nurse is caring for a client who is scheduled for a blood sampling for a serum creatinine level. The client asks the nurse, "What is the purpose of this test?" Which of the following responses should the nurse give?
- A. This test will inform your provider if you are anemic.
- B. This test will inform your provider if you have an infection.
- C. This test will inform your provider how your kidneys are functioning.
- D. This test will inform your provider if you have a thyroid disorder.
Correct Answer: C
Rationale: A serum creatinine test measures the level of creatinine in the blood, which is an indicator of kidney function. Elevated creatinine levels can indicate impaired kidney function or kidney disease.
A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?
- A. Notify the charge nurse.
- B. Check the client's vital signs.
- C. Fill out an occurrence report according to institutional policy.
- D. Document an objective description of what has happened in the client's chart.
Correct Answer: B
Rationale: Checking the client's vital signs is the priority to assess for adverse effects, such as hypotension, ensuring immediate safety.
A nurse is preparing to administer levothyroxine 100 mcg PO daily. Available is levothyroxine 50 mcg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. (Do not use a trailing zero))
Correct Answer: 2 tablets
Rationale: 100 mcg ÷ 50 mcg/tablet = 2 tablets. The nurse should administer 2 tablets.