Nokea
The nurse is caring for a client who is postoperative day 1 after a total shoulder replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of a sling
- B. Administer pain medication as needed
- C. Keep the affected arm in adduction
- D. Monitor the surgical dressing for drainage
Correct Answer: A
Rationale: Using a sling maintains shoulder immobilization, preventing dislocation post-replacement. Options B, C, and D are secondary: pain management is routine, adduction is incorrect, and dressing monitoring is less urgent.
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A client with a family history of Huntington's disease asks the nurse for information on how the disease is transmitted. Which of the following statements indicates that she understands the nurse's teaching?
- A. The chances of my passing the disease to my child are 1 in 2
- B. I have no chance of passing the disease to a male child, but a female child would carry the disease
- C. I have no chance of passing the disease to a female child, but a male child will have the disease
- D. The chances of my passing the disease to my child are 1 in 4
Correct Answer: A
Rationale: Huntington's disease is autosomal dominant, meaning there is a 50% (1 in 2) chance of passing the gene to each child, regardless of sex.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should
- A. place a call to the client's provider for instructions
- B. send him to the emergency room for evaluation
- C. reassure the client's partner that the symptoms are transient
- D. instruct the client's partner to call the provider if his symptoms become worse
Correct Answer: B
Rationale: This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.
An adolescent is to be admitted to the orthopedic floor with several fractures. The client has been taking hallucinogens this evening. What should the nurse expect on admission because the client is using hallucinogens?
- A. Severe depression
- B. Violent behavior
- C. Respiratory distress
- D. Convulsions
Correct Answer: B
Rationale: Hallucinogens can cause agitation or violent behavior due to altered perceptions, especially in a stressful hospital setting. Depression, respiratory distress, or convulsions are less common.
Which of the following statements is both a correctly stated nursing diagnosis and a high priority for a 65-year-old client immediately following a modified radical mastectomy and axillary dissection?
- A. Anxiety related to the mastectomy.
- B. Impaired skin integrity related to the mastectomy.
- C. Pain related to surgical incision.
- D. Self-care deficit related to dressing changes.
Correct Answer: C
Rationale: immediately after surgery, the priority is optimizing the client's comfort
A client develops orthopnea, dyspnea, and basilar crackles.
Which of the following nursing actions would be MOST appropriate for this client?
- A. Elevate the legs to promote venous return.
- B. Decrease the IV fluids and notify the physician.
- C. Orient the client to time, place, and situation.
- D. Prevent complications of immobility.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would worsen the situation (2) correct-orthopnea, dyspnea, and crackles are signs and symptoms of fluid excess; decreasing the IV fluids is the priority (3) not of priority in this situation (4) not of priority in this situation