Nokea
For which of the following preoperative clients should the nurse assess the glucose level? Select all that apply.
- A. A client with diabetes mellitus controlled by diet.
- B. A client with a high stress response to surgery.
- C. A client receiving corticosteroids for the past 3 months.
- D. A client with a family history of diabetes receiving dextrose 5% in lactated Ringer's solution (D5LR) I.V. fluids.
- E. A client who consumes a high carbohydrate diet.
Correct Answer: A,B,C,D
Rationale: Clients at risk for hyperglycemia include those with diabetes (A), high stress response (B, due to cortisol release), recent corticosteroid use (C, which raises glucose), and those receiving dextrose-containing IV fluids with a family history of diabetes (D). A high carbohydrate diet alone (E) is less likely to warrant immediate glucose monitoring.
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While the nurse is providing preoperative teaching, the client says, 'I hate the idea of being an invalid after they cut off my leg.' The nurse's most therapeutic response should be:
- A. You'll still have one good leg to use.'
- B. Tell me more about how you're feeling.'
- C. Let's finish the preoperative teaching.'
- D. You're fortunate to have a wife who can take care of you.'
Correct Answer: B
Rationale: The therapeutic response, 'Tell me more about how you're feeling,' encourages the client to express fears and concerns, facilitating emotional support and coping. The other responses dismiss the client's feelings, prioritize teaching, or make assumptions, which are less therapeutic.
The nurse is assessing a client with a casted arm for signs of infection. Which finding is most concerning?
- A. Mild itching under the cast.
- B. Foul odor from the cast.
- C. Warmth at the cast edges.
- D. Slight swelling of fingers.
Correct Answer: B
Rationale: A foul odor from the cast suggests infection, requiring immediate evaluation.
The nurse is caring for a client who has been prescribed naproxen. Which condition in the client's medical history would require clarification with the primary healthcare provider (PHCP)?
- A. Rheumatoid arthritis (RA)
- B. Congestive heart failure (CHF)
- C. Osteoarthritis
- D. Psoriatic arthritis
Correct Answer: B
Rationale: Naproxen, an NSAID, can exacerbate congestive heart failure by causing fluid retention and increasing cardiac workload.
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following?
- A. Contact the client's audiologist.
- B. Cleanse the hearing aid ear mold in normal saline.
- C. Irrigate the ear canal.
- D. Check the hearing aid's placement.
Correct Answer: D
Rationale: Checking the hearing aid's placement is the first step, as improper placement or a low battery is a common cause of ineffective hearing aid function.
A client is discharged after being hospitalized for thrombophlebitis. She will be driving home with her daughter, who lives 2 hours away. During the 2-hour ride, the nurse should advise the client to:
- A. Perform arm circles while riding in the car
- B. Perform ankle pumps and foot range-of-motion exercises
- C. Elevate her legs while riding in the car
- D. Take an ambulance home
Correct Answer: B
Rationale: Ankle pumps and foot range-of-motion exercises during the car ride promote venous return, preventing stasis and recurrent thrombophlebitis. Arm circles are irrelevant, elevating legs is impractical, and an ambulance is unnecessary for a discharged client.