Nokea
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions is the PRIORITY?
- A. Encourage the client to use the incentive spirometer.
- B. Administer pain medication as needed.
- C. Position the client with the legs abducted.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Positioning with legs abducted prevents hip dislocation, a critical complication post-hip replacement. Options A, B, and D are important but secondary: incentive spirometry prevents pneumonia, pain management supports recovery, and dressing checks monitor bleeding.
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An adult client with a nasogastric tube has an order for acetaminophen (Tylenol) 650 mg PRN for a temperature greater than 101°F (38.3°C).
Which of the following measures should be included by the nurse when administering this medication?
- A. The tablets should be swallowed carefully with sips of water.
- B. The medication should be withheld until the nasogastric tube is removed.
- C. Placement of the nasogastric tube should be checked prior to giving the medication.
- D. Powdered medication should be used and mixed with water to form a solution.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is NPO, so nothing should be administered orally (2) medication should not be withheld (3) correct-liquid acetaminophen may be administered via the nasogastric tube after tube placement has been checked; tube placement should be checked before anything is instilled (4) Tylenol does not come powdered
On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:
- A. Decrease the rate of the intravenous infusion.
- B. Change the type of intravenous fluid being administered.
- C. Change the urinary catheter.
- D. Increase the rate of the intravenous infusion.
Correct Answer: D
Rationale: The urinary output should be maintained between 30 ml and 50 ml per hour. The first action should be to increase the IV rate to prevent increased acidosis. Answer A would lead to diminished output, so it is incorrect. There is no indication that the type of IV fluid is not appropriate as is suggested by answer B, making it incorrect. Answer C would not increase the client's output and would place the client at greater risk for infection, so it is incorrect.
The nurse is teaching a client with newly diagnosed diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak feet in hot water daily.
- B. Apply lotion between the toes.
- C. Trim toenails with rounded edges.
- D. Inspect feet daily for cuts or sores.
Correct Answer: D
Rationale: Daily foot inspection prevents complications like infections in diabetes. Options A, B, and C risk burns, fungal growth, or ingrown nails.
A client with end-stage renal failure is to receive a kidney transplant from her sister. Prior to surgery, the client will be scheduled for:
- A. An intravenous pyelogram
- B. Hemodialysis
- C. A voiding cystogram
- D. A renal biopsy
Correct Answer: B
Rationale: Hemodialysis is typically performed before a kidney transplant to optimize the client's electrolyte and fluid balance, ensuring a stable condition for surgery.
The nurse is providing home care to an 89-year-old man. Which comments by the client indicate a need for further follow up? Select all that apply.
- A. Excuse me if my socks don't match. I can't tell blue from green anymore.
- B. Please don't open the blinds. It hurts my eyes when the sun is bright.
- C. Let me get my reading glasses so I can read that pamphlet.
- D. I don't hear so well, but I don't want a hearing aid. I'm too old to spend that kind of money on myself.
- E. Sometimes I have to check the calendar to be sure what day it is.
- F. My grandchildren call me 'old slowpoke' because I walk slower than they do.
Correct Answer: A,B,D,E
Rationale: Color vision loss, photophobia, hearing loss, and memory issues suggest potential medical issues (e.g., cataracts, glaucoma, hearing impairment, cognitive decline) requiring follow-up.