Nokea
After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching?
- A. To align injured bones.
- B. To provide long-term pull.
- C. To apply 25 lb of traction.
- D. To pull weight with a boot.
Correct Answer: C
Rationale: The amount of traction (e.g., 25 lb) is specific to the injury and not a general purpose, indicating a misunderstanding.
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A client with pancreatic cancer is receiving morphine via a subcutaneous pump. The client is developing drug tolerance. The nurse understands that the client is:
- A. Tolerating the medication well.
- B. Showing addiction to morphine.
- C. Requiring an increased dose.
- D. Experiencing physical dependence.
Correct Answer: C
Rationale: Drug tolerance means the client requires an increased dose to achieve the same pain relief, as the body has adapted to the current dose of morphine.
The home health nurse is discussing the administration of insulin glargine with a client. It would require follow-up if the client states that insulin glargine must be administered
- A. only in the abdomen.
- B. using a 6 mm and 31-gauge insulin syringe.
- C. only with a meal.
- D. after rolling the vial of insulin.
- E. within 28 days of opening the vial.
Correct Answer: A,C,D
Rationale: Insulin glargine can be administered in multiple sites, not only the abdomen; it is given regardless of meals; and it should not be rolled, as it is a clear solution.
A client is receiving vincristine (Oncovin). Client teaching by the nurse should include instructions on:
- A. Use of loperamide (Imodium).
- B. Fluid restriction.
- C. Low fiber, bland diet.
- D. Bowel regimen.
Correct Answer: D
Rationale: Vincristine commonly causes constipation due to neurotoxicity. A bowel regimen (e.g., stool softeners, laxatives) is essential to prevent and manage this side effect.
Which of the following is most effective in assessing the client suspected of developing diabetes insipidus?
- A. Taking vital signs every 2 hours.
- B. Measuring urine output hourly.
- C. Assessing arterial blood gas values every other day.
- D. Checking blood glucose levels.
Correct Answer: B
Rationale: Diabetes insipidus, often caused by head injury, leads to excessive dilute urine output. Hourly urine output measurement is the most effective way to detect this condition early. Vital signs, blood gases, and glucose levels are less specific for this diagnosis.
A client with acute renal failure is prescribed a low-potassium diet. Which food should be avoided?
- A. Bananas.
- B. Rice.
- C. Apples.
- D. Bread.
Correct Answer: A
Rationale: Bananas are high in potassium, unsuitable for a low-potassium diet.