Nokea
The nurse is caring for a client who is postoperative day 1 following a craniotomy. Which of the following positions should the nurse place the client in?
- A. Supine with the head of the bed flat.
- B. Semi-Fowler’s with the head elevated 30°.
- C. Prone with the head turned to one side.
- D. Trendelenburg with the head lowered.
Correct Answer: B
Rationale: semi-Fowler’s position with the head elevated 30° reduces intracranial pressure and promotes venous drainage
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Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?
- A. The client can shave himself and brush his teeth.
- B. The client can transfer himself into and out of his wheelchair.
- C. The client can maneuver his wheelchair without difficulty.
- D. The client can prepare his own well-balanced meals.
Correct Answer: B
Rationale: essential if client is to perform ADLs
When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
- A. Cherry-red urine that gradually becomes clearer
- B. Orange-tinged urine containing particles of calculi
- C. Dark red urine that becomes cloudy in appearance
- D. Dark, smoky-colored urine with high specific gravity
Correct Answer: A
Rationale: Extracorporeal lithotripsy breaks up kidney stones, leading to cherry-red urine from minor bleeding that clears as healing progresses.
The nurse is preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge home. Which of the following statements by the client indicates a need for further teaching by the nurse?
- A. I do not need to limit my time in public places.'
- B. I may share food from serving dishes with others at a restaurant.'
- C. I may use public restrooms.'
- D. I may donate blood.'
Correct Answer: D
Rationale: AIDS patients cannot donate blood due to HIV transmission risk. Public activities and restrooms pose minimal risk, and sharing serving dishes is safe if not directly contaminated.
Which of the following ethnic groups has the highest risk of developing diabetes mellitus type 2 and should be routinely screened for diabetes?
- A. Hispanics
- B. Asians
- C. Caucasians
- D. African-Americans
Correct Answer: A
Rationale: Hispanics (A) have the highest risk for type 2 diabetes due to genetic and socioeconomic factors, requiring routine screening.
Which laboratory test is used to identify injury to the myocardium and can remain elevated for up to 3 weeks?
- A. Total CK
- B. CK-MB
- C. Myoglobin
- D. Troponin T or I
Correct Answer: D
Rationale: Troponin T or I is highly specific for myocardial injury and can remain elevated for up to 2-3 weeks, making it the best marker for detecting cardiac damage.