Nokea
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help:
- A. Prepare the client for ambulation.
- B. Promote urinary and intestinal elimination.
- C. Prevent thrombophlebitis and blood clot formation.
- D. Decrease the likelihood of pressure ulcer formation.
Correct Answer: C
Rationale: Leg exercises prevent venous stasis, reducing the risk of thrombophlebitis and deep vein thrombosis, common complications post-MI due to immobility.
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The nurse is teaching a client with osteoporosis about fall prevention. Which of the following should be included? Select all that apply.
- A. Remove loose rugs from the home.
- B. Install grab bars in the bathroom.
- C. Wear high-heeled shoes for support.
- D. Ensure adequate lighting at night.
- E. Exercise regularly to improve balance.
Correct Answer: A,B,D,E
Rationale: Removing rugs, installing grab bars, ensuring lighting, and exercising prevent falls. High-heeled shoes increase fall risk.
A client is about to have a tympanoplasty, and asks the nurse what the surgical procedure involves. The nurse begins the conversation by:
- A. Assessing the client's understanding of what the physician has explained.
- B. Describing the surgical procedure.
- C. Educating the client that the procedure will close the perforation and prevent recurrent infection.
- D. Informing the client that the procedure will improve hearing.
Correct Answer: A
Rationale: Assessing the client's current understanding allows the nurse to tailor education to the client's knowledge level and address specific concerns effectively.
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.
Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which of the following systems?
- A. Gastrointestinal.
- B. Renal.
- C. Pulmonary.
- D. Cardiac.
Correct Answer: A
Rationale: NSAIDs commonly cause gastrointestinal side effects, such as bleeding or ulcers, so specific assessment of the GI system is critical.
When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following?
- A. Drug-induced hemolytic anemia.
- B. Purpura.
- C. Infectious emboli.
- D. Ecchymosis.
Correct Answer: A
Rationale: Cephalosporins can rarely cause drug-induced hemolytic anemia by triggering an immune response that destroys red blood cells. The nurse should monitor for signs such as jaundice, dark urine, or a drop in hemoglobin. Purpura, infectious emboli, and ecchymosis are not commonly associated with cephalosporin use.