Nokea
The nurse is assisting a client with crutches to ascend stairs. Which instruction is correct?
- A. Step up with the affected leg first.
- B. Use the handrail on the unaffected side.
- C. Advance both crutches to the next step first.
- D. Lean backward while stepping up.
Correct Answer: B
Rationale: Using the handrail on the unaffected side provides stability and safety while ascending stairs.
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Which of the following reasons explains why meperidine (Demerol) is not recommended for chronic cancer-related pain?
- A. It has a high potential for abuse.
- B. It has agonist-antagonist properties.
- C. It must be given intramuscularly to be effective.
- D. It contains a metabolite that causes seizures.
Correct Answer: D
Rationale: Meperidine's metabolite, normeperidine, accumulates with repeated dosing and can cause seizures, making it unsuitable for chronic cancer pain.
The nurse is assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning. Which of the following would pose the greatest hazard to the client as a risk for falling at home?
- A. A 4-year-old cocker spaniel.
- B. Scatter rugs.
- C. Snack tables.
- D. Rocking chairs.
Correct Answer: B
Rationale: Scatter rugs are a significant fall risk due to tripping hazards.
A 68-year-old client with colon cancer experiences an increase in his feelings of anxiety and depression and has suicidal ideation. He appears to be in great distress. The nurse realizes that he is at which stage in his disease?
- A. Initiation of definitive treatment.
- B. End of his first course of treatment.
- C. End stage of his disease.
- D. Recurrence of the disease.
Correct Answer: C
Rationale: Increased anxiety, depression, and suicidal ideation suggest the client is in the end stage of colon cancer, facing mortality and existential distress.
Twenty-four hours after a bone marrow aspiration, the nurse evaluates which of the following as an appropriate client outcome?
- A. The client maintains bed rest.
- B. There is redness and swelling at the aspiration site.
- C. The client requests morphine sulfate for pain.
- D. There is no bleeding at the aspiration site.
Correct Answer: D
Rationale: A successful outcome 24 hours after bone marrow aspiration is no bleeding at the site, indicating proper healing and no complications. Bed rest is not required, redness/swelling suggests infection, and morphine requests indicate uncontrolled pain, which is not expected.
Which of the following is contraindicated for a client diagnosed with disseminated intravascular coagulation (DIC)?
- A. Treating the underlying cause.
- B. Administering heparin.
- C. Administering warfarin sodium (Coumadin).
- D. Replacing depleted blood products.
Correct Answer: C
Rationale: Warfarin is contraindicated in DIC because it further inhibits clotting factors, worsening bleeding. Treating the underlying cause, administering heparin (to stop clotting), and replacing blood products are standard treatments to manage DIC.