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A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?
- A. Remain on bed rest for 24 hours following the procedure.
- B. Participate in range-of-motion exercises.
- C. Use an incentive spirometer every 4 hours.
- D. Place a pillow under your knees while in bed.
Correct Answer: B
Rationale: The correct answer is B: Participate in range-of-motion exercises. Range-of-motion exercises help prevent immobility-related complications such as blood clots and promote circulation postoperatively. This helps prevent complications like deep vein thrombosis. Choices A, C, and D are incorrect. Remaining on bed rest for 24 hours can increase the risk of blood clots. Using an incentive spirometer every 4 hours helps with lung function, not circulation. Placing a pillow under the knees only helps with comfort, not circulation.
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A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?
- A. The nurse should use a filter needle to withdraw the medication.
- B. The nurse should break the neck of the ampule toward their body.
- C. The nurse should use the same needle to draw up and inject the client.
- D. The nurse should dispose of the ampule in the trash can.
Correct Answer: A
Rationale: The correct answer is A. Using a filter needle to withdraw the medication from a glass ampule helps prevent glass particles from contaminating the medication. Breaking the neck of the ampule toward the body (choice B) can lead to injury. Using the same needle to draw up and inject the client (choice C) increases the risk of contamination. Disposing of the ampule in the trash can (choice D) without following proper disposal protocols can be hazardous.
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?
- A. Remove the client's restraint every 4 hr.
- B. Document the client's condition every 15 min.
- C. Request a PRN restraint prescription for clients who are aggressive.
- D. Attach the restraint to the bed's side rail.
Correct Answer: B
Rationale: The correct answer is B: Document the client's condition every 15 min. This guideline is crucial to ensure the safety and well-being of the client in restraints. Documenting the client's condition frequently allows for timely identification of any signs of distress, discomfort, or complications related to the use of restraints. This practice helps in monitoring the client's physical and psychological status, enabling prompt intervention if necessary.
Removing the client's restraint every 4 hours (choice A) is incorrect as it may compromise the client's safety and increase the risk of injury or harm. Requesting a PRN restraint prescription for aggressive clients (choice C) is inappropriate as restraints should only be used as a last resort and not for convenience. Attaching the restraint to the bed's side rail (choice D) is unsafe and restricts the client's movement unnecessarily.
A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take?
- A. Provide frequent rest periods for the client
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions.
- D. Place the client on a low-carbohydrate diet
- E. Instruct the client to avoid blowing their nose forcefully
- F. Assess the client's level of orientation.
Correct Answer: A,B,C,E,F
Rationale: The correct actions for the nurse to take are A, B, C, E, and F. Providing rest periods (A) promotes healing and recovery. Restricting sodium intake (B) is important for certain conditions like hypertension. Advising the client to avoid soap and alcohol-based lotions (C) can prevent skin irritation. Instructing the client to avoid blowing their nose forcefully (E) prevents potential harm to nasal passages. Assessing the client's level of orientation (F) is crucial for monitoring mental status and detecting any changes. These actions prioritize the client's well-being, safety, and overall health.
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.
- A. Limit alcohol intake to 0 oz per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an anti-obesity medication.
- D. Administer an antihypertensive medication.
- E. Limit foods high in potassium.
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A: Limiting alcohol intake helps manage conditions like hypertension. B: Keeping fat intake below 35% helps prevent heart disease. D: Administering antihypertensive medication is essential for managing high blood pressure. C: Administering anti-obesity medication may not be necessary if the client's weight is not the primary concern. E: Limiting foods high in potassium is not necessary unless the client has specific medical conditions requiring it. Therefore, choices C and E are incorrect as they are not the priorities for the client's care in this scenario.
A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment?
- A. Hypertension
- B. Obesity
- C. Hypothyroidism
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. Acupuncture involves inserting needles into specific points on the body to alleviate pain. Herpes zoster, also known as shingles, is a viral infection that causes a painful rash. The presence of open sores or active infection in the area where acupuncture needles would be inserted can lead to complications such as spreading the virus or causing pain. Therefore, it is contraindicated to receive acupuncture treatment when a client has active herpes zoster.
Hypertension (A), obesity (B), and hypothyroidism (C) are not contraindications for acupuncture treatment. Hypertension may actually benefit from acupuncture as it can help reduce stress and improve circulation. Obesity and hypothyroidism do not pose any direct risks for receiving acupuncture treatment.