Nokea
The nurse correctly instructs the client to avoid which type of fluid?
- A. Milk
- B. Alcohol
- C. Cranberry juice
- D. Carbonated drinks
Correct Answer: B
Rationale: Alcohol, especially beer, increases uric acid production and reduces its excretion, worsening gout. Milk, cranberry juice, and carbonated drinks are generally safe unless otherwise contraindicated.
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Which information is most appropriate to teach the client before the arthroscopy procedure?
- A. Signs and symptoms of arthritis
- B. Technique for using crutches
- C. Adverse effects of drug therapy
- D. The need to balance rest and exercise
Correct Answer: B
Rationale: Crutch use is critical post-arthroscopy for safe ambulation.
The nurse gently elevates the client's newly casted arm on a pillow and explains that this is necessary for the first 24 to 48 hours after casting. What is the chief purpose of this action?
- A. It helps a damp cast to dry more evenly.
- B. It reduces the amount of pain medication needed.
- C. Venous return is enhanced, and edema is decreased.
- D. It is more comfortable than keeping the arm dependent.
Correct Answer: C
Rationale: Elevation enhances venous return and reduces edema, the primary reason for this action. It does not directly affect cast drying, pain medication needs, or comfort alone.
The client is ordered to be in a semi-reclining position following a myelogram. The nurse understands that the primary reason for this is which of the following?
- A. To prevent infection
- B. To prevent spinal headache
- C. To prevent seizures
- D. To promote excretion of dye
Correct Answer: B
Rationale: A semi-reclining position post-myelogram prevents spinal headache by reducing cerebrospinal fluid leakage.
After the arm cast has been applied, which nursing observation is the best indication that the client may be developing compartment syndrome?
- A. The client's head becomes severe pain.
- B. The client's hand becomes reddened.
- C. The fingers develop muscle spasms.
- D. The radial pulse feels bounding.
Correct Answer: A
Rationale: Severe pain disproportionate to the injury is a hallmark of compartment syndrome, indicating increased pressure within the cast compromising neurovascular status. Redness, spasms, or a bounding pulse are less specific.
The client is an elderly man who has had diabetes and peripheral vascular disease for several years. He now has had a right below-the-knee amputation. Which preoperative nursing action will do the most to help the client adjust to having an amputation?
- A. Encouraging deep breathing
- B. Asking him if he understands the full effects of the planned surgery
- C. Discussing the effects of diabetes on the vascular system
- D. Having a recovered amputee visit him
Correct Answer: D
Rationale: A visit from a recovered amputee provides peer support, helping the client adjust by seeing a positive outcome.