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The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit?
- A. The client can walk throughout the entire hospital with a walker.
- B. The client can walk the length of a hospital hallway with minimal pain.
- C. The client has increased independence in transfers from bed to chair.
- D. The client can raise the affected leg 6 inches with assistance.
Correct Answer: C
Rationale: Increased independence in transfers is a realistic and measurable goal for discharge.
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Ventricular tachycardia is displayed on the cardiac monitor of a client admitted to the telemetry unit. Which should the nurse do first?
- A. Prepare for immediate cardioversion.
- B. Begin cardiopulmonary resuscitation (CPR).
- C. Check for a pulse.
- D. Prepare for immediate defibrillation.
Correct Answer: C
Rationale: Checking for a pulse determines if ventricular tachycardia is pulseless (requiring defibrillation) or stable (possibly requiring cardioversion or medication).
Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)?
- A. Septic shock.
- B. Chronic obstructive pulmonary disease.
- C. Asthma.
- D. Heart failure.
Correct Answer: A
Rationale: Septic shock is a major ARDS risk factor due to systemic inflammation and lung injury. COPD, asthma, and heart failure are not primary ARDS triggers.
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?
- A. Change dressing per institutional policy.
- B. Culture drainage at insertion site.
- C. Notify physician.
- D. Position rolled towel under client's back, parallel to the spine.
Correct Answer: C,B,A,D
Rationale: The priority is to notify the physician (C) due to potential infection indicated by a moist dressing, followed by culturing drainage (B) to identify the organism, changing the dressing (A) to maintain sterility, and positioning a towel (D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize
The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as an increased risk for developing primary open-angle glaucoma? Select all that apply.
- A. Blue eyes
- B. Older age
- C. African ethnicity
- D. Diabetes mellitus
- E. Use of contact lenses
Correct Answer: B,C,D
Rationale: Older age, African ethnicity, and diabetes mellitus are known risk factors for primary open-angle glaucoma due to increased intraocular pressure susceptibility. Blue eyes and contact lens use are not established risk factors.
Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon?
- A. Showering.
- B. Lifting anything heavier than 10 lb.
- C. A program of gradually progressive walking.
- D. Light housework.
Correct Answer: B
Rationale: Lifting heavy objects (>10 lb) risks sternal dehiscence post-mitral valve replacement, so it is restricted until surgeon approval.