Nokea
Select the hazard of immobility that is accurately paired with an appropriate expected outcome of care that the nurse provides to prevent this complication.
- A. Bone demineralization: Turning and positioning every 2 hours
- B. Urinary stasis: The client will consume 1,000 mL of oral fluids per day
- C. Muscle atrophy: The client will perform range of motion exercises at least 3 times a day
- D. Hypercalcemia: Maintaining fluid intake of 1,000 mL per day
Correct Answer: C
Rationale: Range of motion exercises help prevent muscle atrophy by maintaining muscle strength and function in immobile clients.
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The nurse is caring for a client with a spinal cord injury at the T4 level. Which of the following findings indicates autonomic dysreflexia?
- A. Bradycardia and hypertension.
- B. Tachycardia and hypotension.
- C. Fever and chills.
- D. Hypoxia and cyanosis.
Correct Answer: A
Rationale: Autonomic dysreflexia presents with bradycardia and hypertension due to unopposed sympathetic stimulation below the injury level.
Which of the following statements best explains why the nurse should evaluate gastric residual in administering the client's next enteral feeding?
- A. To determine how well nutrients are being absorbed
- B. To determine if the client is receiving enough feeding
- C. To prevent overdistention of the stomach
- D. To prevent mixing undigested formula with partially digested formula
Correct Answer: C
Rationale: Evaluating gastric residual prevents overdistention of the stomach, which can lead to aspiration or discomfort. It does not directly assess nutrient absorption or feeding adequacy.
Which type of legal consent is indirectly given by the client by the very nature of their voluntary acute care hospitalization?
- A. An opt out consent
- B. An implicit consent
- C. An explicit consent
- D. No consent at all is given
Correct Answer: B
Rationale: Implicit consent is given by the client's voluntary admission to an acute care facility, implying agreement to routine treatments and procedures necessary for their care, unless explicitly refused.
A primary concern of the hospitalized adolescent is:
- A. Respect for the need for privacy.
- B. Allowing parents to visit after hours.
- C. Wearing a hospital gown.
- D. The fear of loss of control when in pain.
Correct Answer: A
Rationale: Adolescents value autonomy and privacy, which is a primary concern during hospitalization, as it supports their developmental need for independence.
A client with a history of peptic ulcer disease is prescribed sucralfate (Carafate). The nurse should instruct the client to:
- A. Take the medication 1 hour before meals.
- B. Take the medication with meals.
- C. Take the medication at bedtime.
- D. Stop the medication if constipation occurs.
Correct Answer: A
Rationale: Sucralfate should be taken 1 hour before meals to coat the stomach lining and protect ulcers.