Nokea
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions should the nurse prioritize?
- A. Encourage early ambulation.
- B. Administer pain medication as needed.
- C. Keep the affected leg in adduction.
- D. Monitor the incision for drainage.
Correct Answer: A
Rationale: Early ambulation prevents complications like thrombosis and promotes recovery. Options B, C, and D are secondary or incorrect.
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The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?
- A. Daily needs and concerns
- B. The overview cardiac rehabilitation
- C. Medication and diet guideline
- D. Activity and rest guidelines
Correct Answer: A
Rationale: At 2 days post-MI, the client's education should be focused on the immediate needs and concerns for the day.
A woman who was recently widowed says to the nurse, 'I just can't believe he's gone. Sometimes I even think I see him standing there.' What does this comment indicate about the client?
- A. She is in an early stage of normal grief.
- B. She may be hallucinating.
- C. She may be having illusions.
- D. She may be in a severe depression.
Correct Answer: A
Rationale: Disbelief and transient perceptions of the deceased are normal in early grief. Hallucinations, illusions, or depression require more persistent or severe symptoms.
A client with a temperature of 103°F (39.4°C).
Body compensatory mechanisms would include which of the following?
- A. Decreased respiratory rate and bradycardia.
- B. Normal blood pressure and pulse.
- C. Increased respiratory rate and tachycardia.
- D. Diaphoresis with cool, clammy skin.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) respirations and heart rate will increase with fever (2) blood pressure and pulse usually increase with fever (3) correct-hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate (4) diaphoresis may occur, but the skin will be warm
The client has recently had a colostomy. The nurse is providing home care and is teaching the client about care of his colostomy. Which comment by the client indicates understanding of the care of his colostomy?
- A. I will use hot water to irrigate the colostomy.'
- B. If my skin gets red, I will put alcohol on it.'
- C. I will irrigate the colostomy at the same time each day.'
- D. I should do the irrigation while lying in bed.'
Correct Answer: C
Rationale: Regularly timed colostomy irrigation promotes predictable bowel patterns, indicating understanding. Hot water, alcohol, or bed irrigation are incorrect.
The nurse is caring for a client with a history of bipolar disorder.
- A. Which client statement indicates a need for further teaching about lithium therapy?
- B. I’ll drink plenty of water every day.'
- C. I’ll have my blood levels checked regularly.'
- D. I can stop the medication if I feel better.'
- E. I’ll avoid eating foods high in sodium.'
Correct Answer: C
Rationale: Stating that the medication can be stopped when feeling better indicates a misunderstanding, as lithium requires consistent use to maintain therapeutic levels and prevent mood swings. Hydration, blood monitoring, and sodium awareness are correct.