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The nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit in during the first 6 to 8 weeks after surgery. Which would be the correct type to recommend?
- A. A desk-type swivel chair.
- B. A padded upholstered chair.
- C. A high-backed chair with armrests.
- D. A recliner with an attached footrest.
Correct Answer: C
Rationale: A high-backed chair with armrests supports proper posture and safe transfers.
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The primary reason for infusing blood at a rate of 60 mL/hour is to help prevent which of the following complications?
- A. Emboli formation.
- B. Fluid volume overload.
- C. Red blood cell hemolysis.
- D. Allergic reaction.
Correct Answer: B
Rationale: A slow infusion rate (60 mL/hour) prevents fluid volume overload, especially in clients at risk post-trauma. Emboli, hemolysis, and allergic reactions are less directly related to infusion rate.
A client with acute renal failure has metabolic acidosis. The nurse expects:
- A. Sodium bicarbonate administration.
- B. Increased potassium intake.
- C. Fluid bolus.
- D. High-protein diet.
Correct Answer: A
Rationale: Sodium bicarbonate corrects metabolic acidosis in acute renal failure.
A nurse is teaching a client about taking antihistamines. Which of the following instructions should the nurse include in the teaching plan? Select all that apply.
- A. Operating machinery and driving may be dangerous while taking antihistamines.
- B. Committaking antihistamines even if nasal infection develops.
- C. The effect of antihistamines is not felt until a day later.
- D. Do not use alcohol with antihistamines.
- E. Increase fluid intake to 2,000 mL/day.
Correct Answer: A,D,E
Rationale: Antihistamines have an anticholinergic action and a drying effect and reduce nasal, salivary, and lacrimal gland hypersecretion (runny nose, tearing, and itching eyes). An adverse effect is drowsiness, so operating machinery and driving are not recommended. There is also an additive depressant effect when alcohol is combined with antihistamines, so alcohol should be avoided during antihistamine use. The client should ensure adequate fluid intake of at least 8 glasses per day due to the drying effect of the drug.
Appropriate nursing diagnoses for a client with hypothyroidism would include which of the following?
- A. Risk for injury (corneal abrasion) related to incomplete closure of the eyelid.
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolism.
- C. A clinical evidence related to diarrhea.
- D. Activity intolerance related to fatigue associated with the disorder.
Correct Answer: D
Rationale: Hypothyroidism causes fatigue due to slowed metabolism, making activity intolerance a relevant nursing diagnosis. The other options are more associated with hyperthyroidism or unrelated conditions.
The nurse should assess the client with Ménière'sdisease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply.
- A. Antihistamines.
- B. Antiemetics.
- C. Diuretics.
- D. Non-steroidal anti-inflammatory drugs (NSAIDs).
- E. Antipyretics.
Correct Answer: A,B,C
Rationale: Common medications for Ménière'sdisease include antihistamines (e.g., meclizine) to reduce vertigo, antiemetics to control nausea, and diuretics to reduce inner ear fluid, all aimed at symptom management.