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A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?
- A. Administer enemas 2 days before the procedure.
- B. Do not eat or drink anything except water for 12 hr. before the procedure.
- C. Restrict the diet to clear liquids for 1 to 3 days before the procedure.
- D. Expect the provider to schedule another procedure to remove any polyps.
Correct Answer: B
Rationale: Fasting except for water 12 hours prior ensures a clear colon for the colonoscopy. Enemas aren't standard, clear liquids are typically 24 hours, and polyp removal occurs during the procedure.
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A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
- A. Obtain blood pressure readings using the client's right arm.
- B. Limit range-of-motion exercises with the affected arm.
- C. Keep both arms below the level of the client's heart.
- D. Use the client's left arm to obtain blood samples.
- E. Elevate the right arm.
- F. Apply compression bandages.
- G. Avoid tight clothing.
Correct Answer: D
Rationale: Using the left arm prevents trauma to the right side, reducing lymphedema risk; BP on the affected arm increases risk.
A nurse in a provider's office is assisting in the care of a client. Complete the following sentence: The first action the nurse should take is to reinforce education about...
- A. nutritional supplements followed by collecting data about nutritional intake.
- B. increasing fluid intake followed by monitoring respiratory rate.
- C. checking blood pressure followed by administering oxygen.
- D. assessing fatigue followed by ordering a chest X-ray.
Correct Answer: A
Rationale: The client's generalized weakness, fatigue, shortness of breath, and pale mucous membranes (Exhibit 1) with a vegan diet suggest anemia, likely iron deficiency. Reinforcing education about nutritional supplements (e.g., iron, Bâ‚â‚‚) addresses potential deficiencies vegans risk low iron and Bâ‚â‚‚ without fortified foods while collecting intake data identifies dietary gaps, guiding tailored therapy. Increasing fluids and monitoring respiration might help hydration or respiratory distress, but anemia is the primary issue, not fluid status. Checking blood pressure (132/60 to 102/50 mm Hg) shows orthostasis, a symptom, not the cause oxygen isn't indicated with 94% saturation. Assessing fatigue is ongoing, but a chest X-ray targets lungs, not anemia. Education and data collection tackle the root nutritional cause, aligning with holistic care and prevention, making it the nurse's first action.
A nurse is initiating the use of a continuous passive motion (CPM) device for a client following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Set the degree of flexion and extension as tolerated by client.
- B. Pad the CPM device with a thick pillow.
- C. Place the client in high-Fowler's position.
- D. Align the client's joints with the joints on the frame.
Correct Answer: D
Rationale: Aligning the client's joints with the CPM frame ensures proper movement and prevents injury. Flexion/extension should be preset by the provider, padding isn't typically needed, and high-Fowler's position is inappropriate for this therapy.
A nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take? (Select all that apply.)
- A. Maintain skin integrity over the blisters
- B. Apply ice to the larger blisters.
- C. Administer ibuprofen for pain.
- D. Run cool water over the affected area.
- E. Allow the affected area to remain open to air.
Correct Answer: A,C,D
Rationale: Blister integrity (A), pain relief with ibuprofen (C), and cool water (D) are correct. Ice can worsen damage, and open air isn't recommended initially.
A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps?
- A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
- B. Check the medication administration record to verify the client's allergies.
- C. Slowly inject the medication into the site without aspirating.
- D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle.
- E. Ensure an air bubble is present in the prefilled enoxaparin syringe.
Correct Answer: B,E,A,D,C
Rationale: The sequence is: Verify allergies (B), check the air bubble (E), locate the site (A), pinch and inject at 90° (D), and inject slowly without aspirating (C) per enoxaparin protocol.