Nokea
The client newly diagnosed with osteoporosis is prescribed calcitonin by nasal spray. Which assessment data indicate to the nurse an adverse effect of the medication?
- A. The client complains of nausea and vomiting.
- B. The client is drinking two (2) glasses of milk a day.
- C. The client has a runny nose and nasal itching.
- D. The client has had numerous episodes of nosebleeds.
Correct Answer: C
Rationale: Runny nose and nasal itching are common adverse effects of nasal calcitonin. Nausea is less common, milk intake is unrelated, and nosebleeds are not typical.
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The 35-year-old client who sustained a crushing injury to the left hand and forearm is being discharged. Which referral should the nurse implement?
- A. Refer the client to physical therapy at home.
- B. Refer the client to an assistive living facility.
- C. Refer the client to a workforce commission for job training.
- D. Refer the client to the dietitian.
Correct Answer: A
Rationale: Home PT restores hand/forearm function post-crushing injury. Assisted living, job training, and dietitian referrals are premature or unrelated.
Which diagnostic test result should the nurse monitor when assessing for evidence of metastasis?
- A. Lung scan
- B. Urinalysis
- C. Spinal tap
- D. Blood glucose
Correct Answer: A
Rationale: A lung scan can detect metastasis of a skeletal tumor to the lungs, a common site for bone cancer spread. Urinalysis, spinal tap, and blood glucose are less relevant for metastasis.
When the nurse makes rounds at the beginning of the shift, which observation requires the nurse's immediate attention?
- A. The halter rests under the client's chin and occiput.
- B. The client's ears are clear of the traction ropes.
- C. The weight hangs between the headboard and wall.
- D. There is a soft pillow beneath the client's head.
Correct Answer: D
Rationale: A pillow under the head in cervical traction can alter the alignment and reduce traction effectiveness, requiring immediate removal. The other observations indicate proper setup.
The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first?
- A. Wrap the left hand with towels and apply pressure.
- B. Instruct the friend to hold his hand above his head.
- C. Apply pressure to the radial artery of the left hand.
- D. Go into the friend's house and call 911.
Correct Answer: A
Rationale: Applying pressure with towels controls bleeding, the priority in traumatic amputation. Elevation is secondary, radial pressure is less effective, and calling 911 delays hemorrhage control.
Which interventions should be included in the discharge teaching for a client who had a total hip replacement? Select all that apply.
- A. Discuss the client’s weight-bearing limits.
- B. Request the client demonstrate use of assistive devices.
- C. Explain the importance of increasing activity gradually.
- D. Instruct the client not to take medication prior to ambulating.
- E. Tell the client to ambulate with open-toed house shoes.
Correct Answer: A,B,C
Rationale: Weight-bearing limits, assistive device use, and gradual activity prevent complications post-THR. Pain medication aids ambulation, and open-toed shoes are unsafe.