Nokea
The nurse is caring for a client with a history of a total knee replacement. The client complains of pain and swelling. The nurse should:
- A. Apply ice to the knee
- B. Elevate the leg
- C. Administer aspirin
- D. Notify the physician immediately
Correct Answer: A
Rationale: Ice reduces pain and swelling post-total knee replacement by decreasing inflammation. Elevation is helpful, aspirin requires an order, and notification is needed if symptoms persist.
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A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which medication would the nurse expect to administer?
- A. Ibuprofen (Advil)
- B. Omeprazole (Prilosec)
- C. Aspirin
- D. Acetaminophen (Tylenol)
Correct Answer: B
Rationale: Omeprazole, a proton pump inhibitor, reduces acid production, aiding ulcer healing. Ibuprofen (A) and aspirin (C) worsen ulcers, and acetaminophen (D) addresses pain but not acid.
A client with a history of endometrial cancer is admitted with complaints of vaginal bleeding. The nurse should give priority to:
- A. Monitoring for recurrence
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Vaginal bleeding in endometrial cancer may indicate recurrence, so monitoring for recurrence is the priority.
The nurse is providing dietary teaching for a client with hypertension. Which food should be avoided by the client on a sodium-restricted diet?
- A. Dried beans
- B. Swiss cheese
- C. Peanut butter
- D. Colby cheese
Correct Answer: D
Rationale: Colby cheese is high in sodium, which should be avoided on a sodium-restricted diet to manage hypertension, unlike the other options, which are lower in sodium.
The client is admitted with a diagnosis of acute glomerulonephritis. Which assessment finding is most expected?
- A. Hematuria
- B. Hypotension
- C. Weight loss
- D. Clear urine
Correct Answer: A
Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation and damage, leading to blood in the urine. Hypertension, weight gain, and oliguria are more common than hypotension, weight loss, or clear urine.
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
- A. Maintaining seizure precautions
- B. Restricting fluid intake
- C. Increasing sensory stimuli
- D. Applying ankle and wrist restraints
Correct Answer: A
Rationale: These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. Fluid intake should be increased to prevent dehydration. Environmental stimuli should be decreased to prevent precipitation of seizures. Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.