Nokea
Bone resorption is a possible complication of Cushing's disease. Which of the following interventions should the nurse recommend to help the client prevent this complication?
- A. Increase the amount of potassium in the diet.
- B. Maintain a regular program of weight-bearing exercise.
- C. Limit dietary vitamin D intake.
- D. Perform isometric exercises.
Correct Answer: B
Rationale: Weight-bearing exercise promotes bone density, counteracting bone resorption caused by excess cortisol in Cushing's disease.
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Which symptom suggests worsening neurological status in a client with a head injury?
- A. Improved orientation.
- B. Decreased pulse rate.
- C. Stable blood pressure.
- D. Mild fatigue.
Correct Answer: B
Rationale: Decreased pulse rate (bradycardia) may indicate increased intracranial pressure, a sign of worsening neurological status.
A client with a surgical wound reports itching around the incision site on postoperative day 5. The nurse should:
- A. Apply an antihistamine cream.
- B. Assess the wound for signs of infection.
- C. Instruct the client to avoid scratching.
- D. Clean the wound with alcohol.
Correct Answer: C
Rationale: Itching is common during healing, but scratching can disrupt the incision. Instructing the client to avoid scratching prevents wound dehiscence while further assessment can rule out infection.
The nurse teaches the client with an ileal conduit measures to prevent a urinary loss. Which of the following measures would be most effective?
- A. Avoid people with respiratory tract infections.
- B. Maintain a daily fluid intake of 2,000 to 3,000 mL.
- C. Use sterile technique to change the appliance.
- D. Irrigate the stoma daily.
Correct Answer: B
Rationale: Maintaining high fluid intake (2,000-3,000 mL) prevents urinary stasis and infection, the most effective measure for reducing urinary loss risk.
A client on peritoneal dialysis reports cloudy effluent. The nurse should:
- A. Continue the exchange.
- B. Notify the physician.
- C. Increase dwell time.
- D. Administer pain medication.
Correct Answer: B
Rationale: Cloudy effluent suggests peritonitis, requiring immediate medical attention.
The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to:
- A. Observe careful hand-washing procedures.
- B. Clean the incisional area with an antiseptic.
- C. Use prepackaged sterile dressings to cover the incision.
- D. Place soiled dressings in a waterproof bag before disposing of them.
Correct Answer: A
Rationale: Hand-washing is the most effective measure to prevent wound infection, as it reduces the risk of introducing pathogens during dressing changes.