Nokea
The nurse is caring for a client with a spinal cord injury at C5. Which complication should the nurse monitor for?
- A. Respiratory distress
- B. Urinary retention
- C. Pressure ulcers
- D. All of the above
Correct Answer: D
Rationale: A C5 spinal cord injury can cause respiratory distress (diaphragm impairment), urinary retention (loss of bladder control), and pressure ulcers (immobility), requiring comprehensive monitoring.
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A client with a history of osteoarthritis is prescribed ibuprofen. The nurse should instruct the client to take the medication:
- A. On an empty stomach to enhance absorption.
- B. With food to reduce gastrointestinal irritation.
- C. At bedtime to promote sleep.
- D. With a diuretic to reduce swelling.
Correct Answer: B
Rationale: Ibuprofen should be taken with food to minimize gastrointestinal irritation and reduce the risk of ulcers.
The nurse is caring for a client who has just undergone a thyroidectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?
- A. Hypocalcemia.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Hypocalcemia is a potential complication post-thyroidectomy due to accidental removal or damage to the parathyroid glands.
A client with a fractured femur is in skeletal traction. The nurse should assess for which of the following complications?
- A. Fat embolism.
- B. Hypovolemia.
- C. Osteomyelitis.
- D. Pressure ulcers.
Correct Answer: A, D
Rationale: Fat embolism is a risk with long bone fractures, and pressure ulcers can develop due to immobility in traction.
The doctor orders a midstream urine specimen for your client who is an alert, oriented and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen?
- A. The need to cleanse the perineal area with circular wipes.
- B. The need to cleanse the perineal area from the 'dirtiest' to the 'cleanest'.
- C. The need to use a new antiseptic wipe for each wipe from the inner to the outer labia.
- D. The need to use a new antiseptic wipe for each wipe from the outer to the inner labia.
Correct Answer: C
Rationale: For a midstream urine specimen, the perineal area should be cleansed from front to back (inner to outer labia) using a new antiseptic wipe for each stroke to prevent contamination.
A client with a history of type 2 diabetes mellitus is prescribed pioglitazone (Actos). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Weight gain.
- C. Hypertension.
- D. Dry skin.
Correct Answer: B
Rationale: Pioglitazone can cause weight gain due to fluid retention, requiring monitoring in diabetic clients.