Nokea
A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make?
- A. Twist at the waist when standing from a seated position.'
- B. Use a raised toilet seat to maintain your hips above your knees.'
- C. Apply a heating pad to the operative hip to decrease pain.'
- D. Move your stronger leg first when using a walker.'
Correct Answer: B
Rationale: The correct answer is B: Use a raised toilet seat to maintain your hips above your knees. This is important post-total hip arthroplasty to prevent hip dislocation. By keeping the hips above the knees, it reduces stress on the hip joint.
Incorrect choices:
A: Twisting at the waist can strain the hip joint post-surgery.
C: Applying heat can increase inflammation and risk of infection.
D: Moving the stronger leg first can lead to uneven weight distribution, increasing the risk of falls.
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A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through airborne transmission, so implementing airborne precautions is essential to prevent the spread of the disease. This includes wearing an N95 mask, placing the client in a negative pressure room, and ensuring proper ventilation. Standard precautions (choice A) are used for all clients, not specifically for tuberculosis. Contact precautions (choice C) are used for diseases spread by direct contact, while droplet precautions (choice D) are used for diseases spread through respiratory droplets, not airborne transmission like tuberculosis.
A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?
- A. Instruct the client to avoid eating raw vegetables.
- B. Remind the client of the importance of medication adherence.
- C. Tell the client to avoid places where there are large crowds of people.
- D. Initiate a referral for the client to a home health agency.
Correct Answer: B
Rationale: Correct Answer: B. Remind the client of the importance of medication adherence.
Rationale: Ensuring medication adherence is crucial for managing AIDS. By reminding the client of this, the nurse advocates for the client's health and well-being. This action promotes the client's self-care and disease management, ultimately empowering the client to take control of their health.
Summary of other choices:
A: Instructing the client to avoid eating raw vegetables is not directly related to client advocacy in the context of AIDS management.
C: Telling the client to avoid large crowds does not directly address the client's ability to continue self-care at home.
D: Initiating a referral to a home health agency may be helpful but does not directly demonstrate client advocacy in this scenario.
A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long-term glycemic control?
- A. Postprandial blood glucose level
- B. Glycosylated hemoglobin level
- C. Fasting blood glucose level
- D. Oral glucose tolerance test results
Correct Answer: B
Rationale: The correct answer is B: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. Monitoring glycosylated hemoglobin levels helps assess the effectiveness of the client's diabetes management plan over time.
A: Postprandial blood glucose level reflects short-term control after a meal.
C: Fasting blood glucose level reflects current blood glucose levels but not long-term control.
D: Oral glucose tolerance test results evaluate how the body handles glucose, not long-term control.
In summary, monitoring glycosylated hemoglobin levels is crucial for assessing long-term glycemic control in clients with diabetes.
A nurse is assessing a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Maintain abduction of the affected extremity.
- B. Position the client in high Fowler’s position.
- C. Encourage the client to cross their legs at the ankles.
- D. Have the client bend forward at the waist while sitting.
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. After a total hip arthroplasty, maintaining abduction of the affected extremity helps prevent dislocation of the hip prosthesis. This position helps stabilize the hip joint and reduces the risk of complications. Option B (Position the client in high Fowler's position) is incorrect as it does not directly address the postoperative care specific to a total hip arthroplasty. Option C (Encourage the client to cross their legs at the ankles) is incorrect because crossing legs can create pressure on the hip joint and increase the risk of dislocation. Option D (Have the client bend forward at the waist while sitting) is incorrect as this could also increase the risk of hip dislocation.
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
- A. Maintain low intermittent suction.
- B. Clamp the NG tube every 2 hours.
- C. Remove the NG tube immediately.
- D. Encourage high-fiber foods.
Correct Answer: A
Rationale: The correct answer is A: Maintain low intermittent suction. This is because in a small bowel obstruction, the NG tube helps decompress the bowel by removing gastric contents and relieving pressure. Low intermittent suction helps prevent excessive suction which can cause tissue damage.
Clamping the NG tube every 2 hours (choice B) is incorrect as it will prevent the tube from effectively decompressing the bowel. Removing the NG tube immediately (choice C) is also incorrect as it is needed for decompression. Encouraging high-fiber foods (choice D) is contraindicated as they can worsen the obstruction.