Nokea
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
- A. Back at the level of the client's scapula.
- B. Back and head that are high.
- C. Seat that is lower than normal.
- D. Seat with firm cushions.
- E. Chair controlled by client's breath.
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.
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Which teaching point is critical for a client with a new diagnosis of epilepsy?
- A. Avoid driving until seizures are controlled.
- B. Limit all social activities.
- C. Discontinue medications if seizures stop.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Avoiding driving until seizures are controlled is critical for safety in epilepsy management.
Which of the following items of documentation is not required for the nurse to have on the chart before the client is transported to the operating suite?
- A. Operative consent.
- B. History and physical information.
- C. Laboratory test results.
- D. Anesthesia note.
Correct Answer: D
Rationale: The anesthesia note is completed intraoperatively or post-procedure by the anesthesiologist. The other documents are required preoperatively to ensure informed consent and medical readiness.
What is the purpose of sodium polystyrene sulfonate in acute renal failure?
- A. Lower blood pressure.
- B. Reduce serum potassium.
- C. Increase urine output.
- D. Correct acidosis.
Correct Answer: B
Rationale: Sodium polystyrene sulfonate removes potassium from the body, treating hyperkalemia.
A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss?
- A. Hypotension.
- B. Decreased serum potassium level.
- C. Rapid, deep respirations.
- D. Warm, dry skin.
Correct Answer: C
Rationale: Rapid, deep respirations (Kussmaul respirations) in diabetic ketoacidosis are a compensatory mechanism for acidosis, leading to significant fluid loss through hyperventilation.
The nurse is caring for a 78-year-old male with lung cancer who is receiving chemotherapy. The client states he is not eating well but otherwise feels healthy. Which meal suggestion would be best for this client?
- A. Local health milk and strawberries.
- B. Toast, gelatin dessert, and cookies.
- C. Broiled chicken, green beans, and cottage cheese.
- D. Steak and french fries.
Correct Answer: C
Rationale: Broiled chicken, green beans, and cottage cheese provide high protein and nutrients with low fat, which is ideal for a client with poor appetite during chemotherapy to support nutrition without being heavy.