Nokea
The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching?
- A. The axillary pads are torn and show signs of wear
- B. The client has a 30-degree bend at the elbow when walking
- C. The crutches and injured foot are moved simultaneously in a 3-point gait
- D. There is a 3 finger-width space noted between the axilla and axillary pad
Correct Answer: A
Rationale: Torn axillary pads can cause discomfort and injury, indicating a need for replacement and further teaching.
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The nurse is teaching the parent of a 6-year-old client about sleep. Which of the following information should the nurse include? Select all that apply.
- A. Your child should sleep 9 to 12 hours every night.
- B. As your child grows, the hours of required sleep increase.
- C. Encourage active play before bedtime to promote restful sleep.
- D. Avoid giving your child large amounts of liquid after dinnertime.
- E. It is important to establish and maintain a regular bedtime routine.
Correct Answer: A,D,E
Rationale: Children aged 6 need 9-11 hours of sleep, limited liquids prevent bedwetting, and routines promote sleep. Sleep needs decrease with age, and active play close to bedtime may disrupt sleep.
The evening nurse caring for an adult who had a partial gastrectomy this morning notes that the drainage from the nasogastric tube is bright red. What action should the nurse take?
- A. Chart the drainage amount and color
- B. Report the findings immediately to the charge nurse
- C. Disconnect the drainage system
- D. Immediately apply pressure to the wound
Correct Answer: B
Rationale: Bright red nasogastric drainage suggests active bleeding post-gastrectomy, requiring immediate reporting to assess for hemorrhage.
A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to reinforce which instruction to the client?
- A. Avoid a high-potassium diet
- B. Exercise regularly and maintain a high-fiber diet
- C. Maintain oral hygiene
- D. Report excessive urination and increased thirst
Correct Answer: D
Rationale: Lithium can cause polyuria and polydipsia due to its effect on renal function. These symptoms may indicate lithium toxicity or diabetes insipidus, which require immediate medical attention.
Which of the following meals would be best tolerated by the client receiving Leukeran?
- A. Peanut butter sandwich, orange juice, and Jell-0
- B. Warm pea soup, apricot fruit slush, and ice cream
- C. Lasagna with meat sauce, salad, and tea
- D. Steak, baked potato, and milk
Correct Answer: B
Rationale: Leukeran can cause nausea, so bland, cool foods like pea soup, fruit slush, and ice cream are better tolerated than heavy or acidic meals.
An 8-month-old infant is scheduled for balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding could possibly delay the procedure and should be reported?
- A. Auscultation of a loud heart murmur
- B. Infant has been npo for 4 hours
- C. Infant has polycythemia
- D. Infant has severe diaper rash
Correct Answer: D
Rationale: Severe diaper rash may increase infection risk during catheterization, potentially delaying the procedure.