Nokea
The nurse is assisting a 58-year-old woman from the bed to the chair for the first time after a right total hip replacement. It is MOST important for the nurse to take which of the following actions?
- A. Assist the patient to stand on her right leg and pivot to a low soft chair, keeping her hips straight.
- B. Assist the patient to stand on her left leg and pivot to a straight-backed chair, flexing her hips slightly.
- C. Ask the patient to bear weight equally on both legs, bend at the waist, and sit in a low soft chair.
- D. Assist the patient to stand on both legs and take a few steps to a straight-backed chair.
Correct Answer: B
Rationale: prevents dislocation
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The nurse is caring for a client with a history of hypothyroidism.
- A. Which symptom is expected in a client with untreated hypothyroidism?
- B. Weight loss and irritability.
- C. Cold intolerance and fatigue.
- D. Tachycardia and heat intolerance.
- E. Diarrhea and restlessness.
Correct Answer: B
Rationale: Cold intolerance and fatigue are classic symptoms of hypothyroidism due to slowed metabolism. Weight loss, tachycardia, and diarrhea are associated with hyperthyroidism.
The physician orders meperidine (Demerol) 50 mg IM every 3-4 h PRN for pain for a client. The client asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse should
- A. take measures to determine if the pain is psychological.
- B. check to see if the man has a history of addiction.
- C. try several other comfort and pain relief measures.
- D. learn the location, character, and intensity of the pain.
Correct Answer: D
Rationale: assessment first step in nursing process
The nurse is caring for a toddler in traction, and the toddler is receiving chloral hydrate (Noctec). The toddler becomes irritable and extremely restless. Which nursing action is MOST appropriate?
- A. Give the next dose of chloral hydrate early.
- B. Contact the physician to obtain new orders.
- C. Instruct the toddler's mother to read to him.
- D. Take the toddler out of traction for 30 minutes.
Correct Answer: B
Rationale: Irritability and restlessness suggest a paradoxical reaction to chloral hydrate, requiring physician notification for medication adjustment. Options A, C, and D are unsafe or ineffective.
A client is scheduled for a cholangiogram. Meglumine diatrizoate (Gastrografin) is ordered for the client.
The nurse should
- A. identify the client before administering the medication.
- B. administer the medication two hours before the procedure.
- C. administer an enema after administering the medication.
- D. instruct the client to take medication slowly with water.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-appropriate identification of client is the first nursing priority after the order is verified (five 'rights' of medication administration) (2) unnecessary (3) unnecessary (4) unnecessary
The nurse is preparing a client for a herniorrhaphy. It would be MOST important for the nurse to complete which of the following one hour prior to surgery?
- A. Administer an enema.
- B. Confirm that the consent form has been signed.
- C. Perform a preoperative shave and scrub.
- D. Evaluate for food or medication allergies.
Correct Answer: B
Rationale: surgical consent should be rechecked prior to going to surgery