Nokea
Following a total hip replacement, the nurse should position the client in which of the following ways?
- A. Place weights alongside of the affected extremity to keep the extremity from rotating.
- B. Elevate both feet on two pillows.
- C. Keep the lower extremities adducted by use of an immobilization binder around both legs.
- D. Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs.
Correct Answer: D
Rationale: Slight abduction prevents dislocation by maintaining proper hip alignment.
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The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate?
- A. Increase calories.
- B. Restrict sodium.
- C. Restrict potassium.
- D. Reduce fat to 10%.
Correct Answer: B
Rationale: Restricting sodium helps manage fluid retention and hypertension in Cushing's disease due to aldosterone excess.
Which of the following interventions would be the most appropriate for preventing the development of a paralytic ileus in a client who has undergone renal surgery?
- A. Encourage the client to ambulate every 2 to 4 hours.
- B. Offer 3 to 4 oz of a carbonated beverage periodically.
- C. Encourage use of a stool softener.
- D. Continue I.V. fluid therapy.
Correct Answer: A
Rationale: Ambulation stimulates bowel motility, reducing the risk of paralytic ileus post-renal surgery by promoting gastrointestinal function.
What areas of education should the nurse provide the narrowness to a factory making the cause respiratory irritation to reduce the risk of laryngeal cancer? Select all that apply.
- A. Smoking cessation concurrent with counseling.
- B. HEPA filter use in the home.
- C. Limiting alcohol use.
- D. Brushing teeth after every meal.
- E. Raising the voice to be heard over the noise in the factory.
Correct Answer: A,C
Rationale: Smoking and excessive alcohol use are major risk factors for laryngeal cancer; cessation and moderation reduce risk. HEPA filters address general air quality but not specific carcinogens. Brushing teeth and raising the voice are unrelated to laryngeal cancer risk.
A client with ulcerative colitis is prescribed mesalamine (Asacol). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Slight rash.
- C. Worsening diarrhea.
- D. Fatigue.
Correct Answer: C
Rationale: Worsening diarrhea in a client with ulcerative colitis taking mesalamine may indicate a lack of therapeutic response or a serious adverse effect, requiring immediate reporting. Mild headache, slight rash, and fatigue are less urgent but should be monitored. CN: Pharmacological and parenteral therapies; CL: Synthesize
A client states that she is afraid of receiving vitamin B12 injections because of potential toxic effects, which is the nurse's best response to relieve these fears?
- A. Vitamin B12 will cause ringing in the ears before a toxic level is reached.'
- B. Vitamin B12 may cause a very mild rash initially.'
- C. Vitamin B12 may cause mild nausea but nothing toxic.'
- D. Vitamin B12 is generally free of toxicity because it is water-soluble.'
Correct Answer: D
Rationale: Vitamin B12 is a water-soluble vitamin, and excess amounts are excreted in urine, making toxicity rare. This response reassures the client by addressing her fear of toxic effects accurately. The other responses are incorrect, as B12 does not typically cause ringing in the ears, rash, or nausea as signs of toxicity.