Nokea
A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?
- A. Elevated toilet seat
- B. Compression stockings
- C. Heating pad
- D. Nebulizer
Correct Answer: A
Rationale: The correct answer is A: Elevated toilet seat. The nurse should ensure the client has this equipment to facilitate safe and easy toileting post-hip arthroplasty. An elevated toilet seat helps prevent excessive bending at the hip joint, reducing strain and risk of injury. Option B, compression stockings, are used for venous circulation and are not specifically required for hip arthroplasty. Option C, a heating pad, may provide comfort but is not essential for postoperative care. Option D, a nebulizer, is used for respiratory conditions and is not relevant to hip arthroplasty.
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A nurse is caring for a 75-year-old client who is admitted to the medical-surgical unit. Which of the following findings indicate the client is most likely experiencing deep vein thrombosis (DVT)?
- A. Unilateral right lower extremity swelling and warmth below the knee
- B. Pain level as 2 on a scale of 0 to 10
- C. Ambulating in hallway with assistance
- D. Not wearing sequential compression devices
Correct Answer: A
Rationale: The correct answer is A. Unilateral right lower extremity swelling and warmth below the knee are classic signs of deep vein thrombosis (DVT). The swelling occurs due to blood clot formation, leading to impaired venous return and warmth due to inflammation. Choice B is incorrect because pain level alone is not a specific indicator of DVT. Choice C is incorrect as ambulating with assistance does not directly relate to DVT. Choice D is incorrect as not wearing sequential compression devices does not definitively indicate DVT.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, the lungs are unable to eliminate enough carbon dioxide, leading to an increase in CO2 levels in the blood, causing acidosis. This is due to inadequate ventilation or impaired gas exchange. The other options are incorrect because: B) Loss of bicarbonate is seen in metabolic acidosis, not respiratory acidosis. C) Excessive vomiting leads to metabolic alkalosis, not respiratory acidosis. D) Hyperventilation would actually correct respiratory acidosis by decreasing CO2 levels.
A nurse is caring for a client who has acute kidney injury and a potassium level of 6.5 mEq/L. Which of the following ECG changes should the nurse expect?
- A. Flattened T waves
- B. Peaked T waves
- C. Prolonged PR interval
- D. ST segment depression
Correct Answer: B
Rationale: The correct answer is B: Peaked T waves. In hyperkalemia (high potassium level), the myocardium becomes more excitable, leading to changes in the ECG. Peaked T waves are a classic sign of hyperkalemia, indicating early stages of cardiac involvement. Flattened T waves (choice A) are associated with hypokalemia. Prolonged PR interval (choice C) and ST segment depression (choice D) are not typically seen in hyperkalemia.
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?
- A. I feel overwhelmed and unsure if I can handle this responsibility.
- B. I changed the floor plan of our home to accommodate my fathers wheelchair.
- C. I wish my siblings would help more with our parents care.
- D. I often feel resentful about the extra responsibilities.
Correct Answer: B
Rationale: The correct answer is B. Changing the floor plan of the home to accommodate the father's wheelchair demonstrates acceptance of the caregiving role. This action shows that the client is willing to make necessary adjustments for their parents' needs, indicating a commitment to the role change.
A: Feeling overwhelmed and unsure indicates resistance to the role change.
C: Wishing for siblings' help suggests a desire to share responsibilities, not necessarily acceptance.
D: Feeling resentful points towards negative emotions, which do not align with acceptance.
A nurse is caring for a client who has dumping syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Iron-deficiency anemia
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Iron-deficiency anemia. Dumping syndrome following a gastric resection can lead to rapid emptying of the stomach contents into the small intestine, causing malabsorption of nutrients, especially iron. Iron-deficiency anemia can develop due to inadequate iron absorption. Monitoring for anemia is crucial in these clients.
Hyperkalemia (A), hypoglycemia (B), and hypertension (D) are not typical complications of dumping syndrome. Hyperkalemia is high potassium levels, hypoglycemia is low blood sugar, and hypertension is high blood pressure, which are not directly associated with dumping syndrome.