Nokea
The nurse is caring for a client who has just undergone a pacemaker insertion. Which of the following instructions should the nurse include in the discharge teaching?
- A. Avoid lifting heavy objects for 4-6 weeks.
- B. Resume driving immediately.
- C. Use a microwave oven without restrictions.
- D. Avoid cell phone use permanently.
Correct Answer: A
Rationale: Avoiding heavy lifting for 4-6 weeks prevents dislodgement of the pacemaker leads during healing.
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The nurse is teaching a client with a new diagnosis of type 1 diabetes mellitus about insulin administration. Which of the following instructions is most important?
- A. Rotate injection sites.
- B. Store insulin in the freezer.
- C. Administer insulin at bedtime only.
- D. Use the same syringe for multiple doses.
Correct Answer: A
Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption.
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?
- A. Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.
- B. Ask the client to assume a side-lying position with the knees flexed.
- C. Perform massage vigorously at the level of the umbilicus if the fundus feels boggy.
- D. Place the client on a bedpan in case the uterine palpation stimulates the client to void.
Correct Answer: A
Rationale: This technique stabilizes the uterus during fundus assessment, preventing discomfort and ensuring accurate palpation.
A client with severe major depression states, 'My heart has stopped and my blood is black ash.' The nurse interprets this statement to be evidence of which of the following?
- A. Hallucination.
- B. Illusion.
- C. Delusion.
- D. Paranoia.
Correct Answer: C
Rationale: The client's statement reflects a false, fixed belief that is not based in reality, which is characteristic of a delusion. Hallucinations involve sensory perceptions, illusions are misinterpretations of stimuli, and paranoia involves suspicion, none of which fit this scenario.
A client with a fractured femur is placed in skeletal traction. The nurse should assess the client for which of the following complications?
- A. Pressure ulcers.
- B. Deep vein thrombosis.
- C. Hypovolemia.
- D. Infection at the pin sites.
Correct Answer: B,D
Rationale: Skeletal traction increases the risk of deep vein thrombosis due to immobility and infection at pin sites due to skin penetration.
The nurse is assessing a client with suspected pulmonary edema. Which of the following findings would support this diagnosis?
- A. Crackles in the lung bases.
- B. Bradypnea.
- C. Hypotension.
- D. Dry cough.
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid accumulation in pulmonary edema.