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A nurse is providing teaching to a client who has osteoporosis about preventing fractures. Which of the following instructions should the nurse include?
- A. Increase your intake of calcium-rich foods.
- B. Avoid weight-bearing exercises.
- C. Perform weight-bearing exercises regularly.
- D. Avoid taking calcium supplements.
Correct Answer: C
Rationale: The correct instruction the nurse should include is to perform weight-bearing exercises regularly. Weight-bearing exercises help maintain bone density and reduce the risk of fractures in clients with osteoporosis. Increasing intake of calcium-rich foods (Choice A) is also beneficial for bone health. Avoiding weight-bearing exercises (Choice B) is incorrect as these exercises are essential for strengthening bones. Avoiding calcium supplements (Choice D) may not be necessary if the client's dietary intake is inadequate.
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What is the most important nursing action for a patient post-surgery?
- A. Monitor vital signs
- B. Monitor the surgical site
- C. Check blood pressure
- D. Check oxygen saturation
Correct Answer: A
Rationale: The most crucial nursing action for a patient post-surgery is to monitor vital signs. Monitoring vital signs helps in detecting early signs of complications such as hemorrhage, shock, or infection. While monitoring the surgical site is important for assessing wound healing and signs of infection, it is secondary to monitoring vital signs. Checking blood pressure and oxygen saturation are also important, but they are components of monitoring vital signs.
Which lab value should be monitored in a patient on digoxin?
- A. Monitor potassium levels
- B. Monitor calcium levels
- C. Monitor digoxin levels
- D. Monitor sodium levels
Correct Answer: C
Rationale: The correct answer is to monitor digoxin levels in a patient on digoxin. Digoxin is a medication commonly used to treat heart conditions, and monitoring its levels in the blood is crucial to ensure that the patient is within the therapeutic range and to prevent toxicity. Monitoring potassium levels (Choice A) is important due to the potential of digoxin-induced hypokalemia, but the primary focus should be on monitoring digoxin levels. Monitoring calcium levels (Choice B) and sodium levels (Choice D) are not directly related to digoxin therapy and are not the primary lab values of concern when administering digoxin.
A nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?
- A. Keep the head of the bed elevated to 30 degrees.
- B. Administer IV antibiotics prophylactically.
- C. Change the catheter insertion site every 24 hours.
- D. Monitor the insertion site for redness.
Correct Answer: D
Rationale: The correct answer is to monitor the insertion site for redness. This intervention helps detect signs of infection early in clients with intraventricular catheters. Keeping the head of the bed elevated to 30 degrees is important for managing intracranial pressure but does not directly reduce the risk of infection. Administering IV antibiotics prophylactically is not recommended as a routine practice due to the risk of antibiotic resistance and should only be done based on culture results. Changing the catheter insertion site every 24 hours is unnecessary and increases the risk of introducing new pathogens.
What is the best method to manage fluid overload in a patient with heart failure?
- A. Administer diuretics
- B. Provide oral fluids
- C. Increase fluid intake
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: Administering diuretics is the best method to manage fluid overload in a patient with heart failure. Diuretics help to remove excess fluid from the body by increasing urine output, thus reducing the fluid volume in the bloodstream and tissues. Providing oral fluids (choice B) or increasing fluid intake (choice C) would exacerbate the fluid overload rather than managing it. Chest physiotherapy (choice D) is not indicated for managing fluid overload in heart failure; it is more commonly used for conditions affecting the lungs or airways.
A nurse is planning care for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis?
- A. Glomerular filtration rate of 14 mL/minute
- B. BUN 16 mg/dL
- C. Serum magnesium 1.8 mg/dL
- D. Serum phosphorus 4.0 mg/dL
Correct Answer: A
Rationale: A glomerular filtration rate of 14 mL/minute indicates severe kidney dysfunction, necessitating hemodialysis. The other options, BUN of 16 mg/dL, serum magnesium of 1.8 mg/dL, and serum phosphorus of 4.0 mg/dL, are within normal ranges and do not serve as indications for hemodialysis.