Following a typanoplasty, the nurse should maintain the client in which position?
- A. Semi-Fowler's with the operative ear facing down
- B. Low Trendelenburg with the head in neutral position
- C. Flat with the head turned to the side with the operative ear facing up
- D. Supine with a small neck roll to allow for drainage
Correct Answer: C
Rationale: After tympanoplasty, the client should be positioned flat with the head turned to the side and the operative ear facing up to promote healing and prevent pressure on the surgical site. Answer A is incorrect because the operative ear should face up, not down. Answer B is incorrect because low Trendelenburg is not indicated. Answer D is incorrect because a neck roll may not ensure proper positioning of the operative ear.
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A client with severe hypertension is receiving Capoten (captopril). The nurse should instruct the client to report which of the following to the doctor?
- A. Coughing
- B. Drowsiness
- C. Frequent urination
- D. Hunger
Correct Answer: A
Rationale: A persistent cough is a common side effect of ACE inhibitors like captopril, potentially requiring a change in medication.
A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?
- A. Moist mucous membranes
- B. Urinary frequency
- C. Poor skin turgor
- D. Increased blood pressure
Correct Answer: C
Rationale: Poor skin turgor. The specific gravity value is high, indicating dehydration. Poor skin turgor (tenting of the skin) is consistent with this problem.
When caring for a client with hypocalcaemia, the nurse should assess for:
- A. A decreased level of consciousness
- B. Tetany
- C. Bradycardia
- D. Respiratory depression
Correct Answer: B
Rationale: Hypocalcemia can cause tetany (muscle spasms or twitching) due to increased neuromuscular excitability.
The nurse is caring for a client who is confused and is in soft wrist restraints. Which tasks can the nurse safely assign to unlicensed assistive personnel? Select all that apply.
- A. Assist the client with using a bedpan
- B. Check circulation and sensation of the extremities
- C. Perform range-of-motion exercises
- D. Report changes in skin integrity
- E. Turn and reposition the client in bed
Correct Answer: A,C,D,E
Rationale: UAP can assist with bedpan use (A), perform range-of-motion exercises (C), report skin changes (D), and reposition the client (E). Checking circulation and sensation (B) requires nursing assessment skills.
The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge?
- A. Client on chemotherapy who started antibiotics today for cellulitis of the leg
- B. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours
- C. Client with diabetes who has nausea, abdominal pain, and vomiting
- D. Client with ulcerative colitis and diarrhea who has developed fever and vomiting
Correct Answer: B
Rationale: The client with resolved asthma exacerbation, not requiring oxygen or nebulizers for 12 hours, is stable and safe for discharge, unlike the others with active complications.
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