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The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order of priority should the nurse assist the client applying the brace?
- A. Have the client in a side-lying position.
- B. Verify the order for the settings for the brace.
- C. Ask the client to stand with arms held away from the body.
- D. Assist the client to log roll and rise to a sitting position.
Correct Answer: B,A,D,C
Rationale: Verifying the order ensures correct settings, side-lying positions the client safely, log rolling prevents twisting, and standing allows proper brace fitting.
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After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help:
- A. Prepare the client for ambulation.
- B. Promote urinary and intestinal elimination.
- C. Prevent thrombophlebitis and blood clot formation.
- D. Decrease the likelihood of pressure ulcer formation.
Correct Answer: C
Rationale: Leg exercises prevent venous stasis, reducing the risk of thrombophlebitis and deep vein thrombosis, common complications post-MI due to immobility.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
- A. Hyperalbuminemia.
- B. Thrombocytopenia.
- C. Hypokalemia.
- D. Hypercalcemia.
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
The nurse should ask all clients age 65 or older who are having surgery which question?
- A. Do you have Medicare Part A to help pay for the hospital reimbursement?'
- B. œDo you have an advance directive such as a health care proxy or living will?'
- C. œDo you have extra coverage to help pay for medications?'
- D. œDo you have Medicare Part B to help pay for your expenses?'
Correct Answer: B
Rationale: Asking about an advance directive ensures the client's wishes are documented, especially critical for older adults facing surgical risks, to guide care in case of incapacity.
A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL and a serum potassium level of 3.5 mEq. The physician has ordered 1,000 mL 5% dextrose in water to be infused every 8 hours. Prior to implementing the physician orders, the nurse should contact the physician, explain the situation, provide background information, report the current assessment of the client, and:
- A. Suggest adding potassium to the fluids.
- B. Request an increase in the volume of intravenous fluids.
- C. Verify the order for 5% dextrose in water.
- D. Determine if the client should be placed in isolation.
Correct Answer: C
Rationale: 5% dextrose in water is inappropriate for a hyperglycemic client (325 mg/dL), as it may worsen hyperglycemia. The nurse should verify the order, likely suggesting normal saline instead.
Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem?
- A. Slow, irregular respirations.
- B. Rapid, shallow respirations.
- C. Asymmetric chest excursion.
- D. Nasal flaring.
Correct Answer: A
Rationale: Slow, irregular respirations (e.g., Cheyne-Stokes or ataxic breathing) are indicative of brain stem dysfunction due to increasing intracranial pressure. Rapid, shallow respirations may indicate hypoxia, asymmetric chest excursion suggests mechanical issues, and nasal flaring is associated with respiratory distress, not specifically ICP.