Nokea
The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment findings should lead the nurse to suspect possible nerve damage?
- A. Numbness.
- B. Bleeding.
- C. Dislocation.
- D. Pinkness.
Correct Answer: A
Rationale: Numbness indicates potential nerve damage, requiring urgent evaluation.
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A client with acute renal failure is at risk for:
- A. Infection.
- B. Hypoglycemia.
- C. Hypernatremia.
- D. Bone fractures.
Correct Answer: A
Rationale: Infection risk is high due to impaired immune response and dialysis access.
What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy?
- A. Antibiotics will need to be taken for 1 to 2 weeks.
- B. Arm exercises will get rid of the cellulitis.
- C. Ice pack should be applied to the affected area for 20 minute periods to reduce swelling.
- D. The right extremity should be lowered to improve blood flow to the forearm.
Correct Answer: A
Rationale: Antibiotics for 1-2 weeks are the primary treatment for cellulitis, a bacterial infection, to prevent complications in a post-mastectomy client with lymphedema risk.
A client is being switched from levodopa (L-dopa) to carbidopa-levodopa (Sinemet). The nurse should monitor for which of the following possible complications during medication changes and dosage adjustment?
- A. Euphoria.
- B. Jaundice.
- C. A military fluctuation.
- D. Signs and symptoms of diabetes.
Correct Answer: B
Rationale: Jaundice may indicate hepatotoxicity, a rare but serious complication of levodopa or carbidopa-levodopa. Euphoria, motor fluctuations, and diabetes are not primary concerns during this switch.
A client with bacterial pneumonia is to be started on I.V. antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins?
- A. Urinalysis.
- B. Sputum culture.
- C. Chest radiograph.
- D. Red blood cell count.
Correct Answer: B
Rationale: A sputum culture identifies the causative organism and its antibiotic sensitivity, guiding effective therapy. Urinalysis, chest radiographs, and red blood cell counts provide supportive data but are not required before starting antibiotics.
A client has been admitted with draining foot lesions. The nurse should do which of the following? Select all that apply.
- A. Place the client in a room with negative air pressure.
- B. Admit the client to a semi-private room.
- C. Admit the client to a private room.
- D. Post a "contact isolation" sign on the door.
- E. Wear a protective gown when in the client's room.
- F. Wear latex-free gloves when providing direct care.
Correct Answer: C,D,E,F
Rationale: Draining lesions require contact precautions, including a private room, isolation signage, gowns, and gloves (latex-free to avoid allergies). Negative pressure is for airborne pathogens.