Nokea
The client asks the nurse what his activity limitations are while he is in Buck's traction. The nurse should tell the client:
- A. You can sit up whenever you want.'
- B. You must lie flat on your back most of the time.'
- C. You can turn your body.'
- D. You must lie on your stomach.'
Correct Answer: B
Rationale: Buck's traction requires lying flat to maintain traction alignment, limiting movement.
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A nurse is planning care for a client who underwent a percutaneous needle biopsy of the kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
- A. Assess the biopsy site.
- B. Take vital signs every hour.
- C. Assess urine for hematuria.
- D. Place the client in a prone position.
- E. Assess the client for chest pain.
Correct Answer: A,C,D
Rationale: Assessing the biopsy site, urine for hematuria, and placing the client prone help monitor for bleeding and promote hemostasis post-biopsy.
A client with Raynaud's phenomenon is prescribed diltiazem (Cardizem). An expected outcome is:
- A. Decreased heart rate
- B. A return to normal sinus rhythm
- C. Reduced episodes of finger numbness
- D. Increased SpO2
Correct Answer: C
Rationale: Diltiazem, a calcium channel blocker, reduces vasospasm in Raynaud's by promoting vasodilation, decreasing episodes of finger numbness. It may lower heart rate or affect rhythm, but these are not primary goals, and SpO2 is not directly improved.
The nurse is assessing a client with age-related cataracts. Which of the following assessment findings would support this diagnosis of age-related cataracts?
- A. peripheral vision loss
- B. central vision loss
- C. difficulty seeing at night, especially while driving
- D. blurred vision with headache
Correct Answer: C
Rationale: Age-related cataracts often cause difficulty seeing at night, particularly while driving, due to lens opacity scattering light. Peripheral vision loss is more associated with glaucoma, central vision loss with macular degeneration, and blurred vision with headache is typical of angle-closure glaucoma.
Following a thoracotomy, the client has severe pain. Which of the following strategies for pain management will be most effective for this client?
- A. Repositioning the client immediately after administering pain medication.
- B. Reassessing the client 30 minutes after administering pain medication.
- C. Verbally reassuring the client after administering pain medication.
- D. Readjusting the pain medication dosage as needed according to the client's condition.
Correct Answer: D
Rationale: Readjusting pain medication dosage based on the client's condition ensures adequate pain control, critical for recovery. Repositioning, reassessing, and reassurance are supportive but less effective alone.
College freshman are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on:
- A. Water sanitation.
- B. Single dormitory rooms.
- C. Vaccine for hepatitis B.
- D. Safe sexual practices.
Correct Answer: D
Rationale: Hepatitis B is transmitted via blood and body fluids, so safe sexual practices (D) are critical for prevention. Water sanitation (A) is more relevant for hepatitis A. Single rooms (B) are unnecessary. The vaccine (C) is preventive but not the focus of behavioral instruction.