Nokea
A woman has undergone a mastectomy of her right breast and has been brought to the recovery unit. The nurse explains that the client should
- A. keep her right arm elevated on a pillow.
- B. keep her right arm elevated above her head.
- C. keep her right arm level with the heart.
- D. keep her right arm slightly lower than her heart.
Correct Answer: A
Rationale: Elevating the arm on a pillow reduces lymphedema risk post-mastectomy by promoting lymphatic drainage.
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The nurse is assessing the reflexes of a full-term newborn infant. Which of the following is true regarding newborn reflexes?
- A. The Babinski reflex disappears after 1 year of age.
- B. Complete fencing response disappears by 2 months.
- C. The stepping or 'walking' reflex is present until 3-4 months.
- D. The Moro reflex is present at birth and disappears by 6 months.
Correct Answer: D
Rationale: The Moro reflex, present at birth, typically disappears by 6 months. Babinski persists until ~2 years, fencing (tonic neck) until 4-6 months, and stepping until 1-2 months.
A med-surg nurse is floating to the post-op floor for a few days. The float nurse sees one of the regular post-op nurses taking medication from the med cart and ingesting several pills. The float nurse should immediately
- A. inform the state board of nursing.
- B. inform the nursing supervisor who works on the post-op floor.
- C. report the nurse to human resources.
- D. confront the post-op nurse about stealing and abusing medications.
Correct Answer: B
Rationale: Reporting to the nursing supervisor ensures prompt investigation and intervention for suspected medication diversion, maintaining patient safety.
The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The most likely explanations for the elevated temperature is that:
- A. There was damage to the hypothalamus.
- B. He has an infection from the abrasions to the head and face.
- C. He will require a cooling blanket to decrease the temperature.
- D. There was damage to the frontal lobe of the brain.
Correct Answer: B
Rationale: Infection from abrasions is the most likely cause of fever post-accident, as it's a common complication.
The nurse is performing discharge teaching to a client newly diagnosed with hypertension and high cholesterol. Which statement by the client indicates that the nurse's teaching was effective?
- A. I need to buy canned foods that are low in sodium.
- B. I can substitute lean sirloin for my homemade fried chicken.
- C. I will take a can of soup to work for lunch instead of eating a burger.
- D. Frozen dinners are better for me than eating in the cafeteria at work.
Correct Answer: B
Rationale: Substituting lean sirloin for fried chicken reduces fat and cholesterol. Canned foods, soups, and frozen dinners are often high in sodium, unsuitable for hypertension.
Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. The nurse realizes that the medication is having a therapeutic effect when the following is noted:
- A. There is an absence of peristalsis.
- B. The number of diarrhea stools decreases.
- C. Cramping in the abdomen has increased.
- D. Abdominal girth size increases.
Correct Answer: B
Rationale: Lomotil is an antidiarrheal that slows intestinal motility, reducing the frequency of diarrhea stools, indicating its therapeutic effect.