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The nurse is caring for a client with a history of a stroke who has hemiparesis. The nurse should:
- A. Position the client on the strong side
- B. Encourage passive range of motion
- C. Provide a high-protein diet
- D. Use a sling for the affected arm
Correct Answer: D
Rationale: A sling supports the affected arm in hemiparesis, preventing subluxation. Positioning varies, passive motion is secondary, and diet depends on needs.
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A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which finding should be reported to the doctor?
- A. A WBC of 14,000 cu.mm
- B. Auscultation of abdominal bruit
- C. Complaints of lower back pain
- D. A platelet count of 175,000 cu.mm
Correct Answer: A
Rationale: A WBC of 14,000 cu.mm indicates possible infection or inflammation, which is concerning pre-surgery and should be reported. Abdominal bruit and lower back pain are expected with an abdominal aortic aneurysm, and a platelet count of 175,000 is normal.
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
- A. I'll be sure to rise slowly and sit for a few minutes after lying down.'
- B. I'll be sure to walk at least 2-3 blocks every day.'
- C. I'll be sure to restrict my fluid intake to four or five glasses a day.'
- D. I'll be sure not to take any more aspirin while I am on this drug.'
Correct Answer: A
Rationale: Rising slowly prevents postural hypotension, a common side effect of furosemide that increases fall risk. The other options are not specific to furosemide therapy risks.
The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:
- A. Offer thin liquids
- B. Position the client upright for meals
- C. Feed the client quickly
- D. Use a straw for fluids
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk in dysphagia post-stroke. Thickened liquids, slow feeding, and avoiding straws are also recommended.
The nurse notes the following laboratory test results on a 24-hour post-burn client. Which abnormality should be reported to the physician immediately?
- A. Potassium 7.5 mEq/L
- B. Sodium 131 mEq/L
- C. Arterial pH 7.34
- D. Hematocrit 52%
Correct Answer: A
Rationale: Hyperkalemia (7.5 mEq/L) is life-threatening, risking arrhythmias, and requires immediate reporting. Hyponatremia (B), slightly low pH (C), and elevated hematocrit (D) are less urgent in early burn care.
A client with a history of liver cirrhosis is admitted with complaints of ascites. The nurse should give priority to:
- A. Monitoring for infection
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering diuretics
Correct Answer: A
Rationale: Ascites increases infection risk (e.g., spontaneous bacterial peritonitis) in cirrhosis, so monitoring for infection is the priority.