Nokea
The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
- A. venous thromboembolism
- B. obstructive sleep apnea
- C. hypostatic pneumonia
- D. aspiration pneumonia
Correct Answer: C
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, reducing the risk of hypostatic pneumonia in postoperative clients with limited mobility. It does not directly prevent venous thromboembolism, obstructive sleep apnea, or aspiration pneumonia.
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The nurse is caring for a client who is 24 hours postoperative following a left total knee replacement. Which assessment data would indicate that the client is ready for discharge?
- A. Pulse (P) 102, RR 18, BP 104/72 mm Hg
- B. Urine output of 200 mL in the past 8 hours
- C. Lung bases are clear upon auscultation
- D. The client rates left knee pain as 8/10 on the Numerical Rating Scale
Correct Answer: C
Rationale: Clear lung bases indicate no respiratory complications, such as pneumonia, which is critical for discharge readiness. A pulse of 102 and low blood pressure (104/72 mm Hg) suggest possible instability, requiring further evaluation. Low urine output (200 mL/8 hours) indicates potential renal issues, and severe pain (8/10) suggests inadequate pain control, both contraindicating discharge.
The nurse is preparing to obtain a wound culture on an infected leg ulcer. Before swabbing the wound to obtain the culture, the nurse should
- A. Clean the wound with sterile saline.
- B. Pat dry the wound with gauze.
- C. Irrigate the wound with hydrogen peroxide.
- D. Don sterile gloves
Correct Answer: A
Rationale: Cleaning with sterile saline removes debris, ensuring an accurate culture. Drying, using peroxide, or sterile gloves (clean gloves suffice) are not appropriate.
The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include?
- A. Keep the crutches 4 in (10 cm) in front of your feet while standing.
- B. When ascending stairs, lead with your unaffected (stronger) leg.
- C. Before sitting down in a chair, move both crutches to the unaffected (stronger) side of the body.
- D. Your shoulders should support your body weight while ambulating with crutches.
Correct Answer: B
Rationale: Leading with the stronger leg when ascending stairs ensures stability. Crutches should be 6-10 inches forward, crutches stay in both hands when sitting, and weight is on hands, not shoulders.
The nurse is caring for a client who is 24 hours postoperative following a left total knee replacement. Which assessment data would indicate that the client is ready for discharge?
- A. Pulse (P) 102, RR 18, BP 104/72 mm Hg
- B. Urine output of 200 mL in the past 8 hours
- C. Lung bases are clear upon auscultation
- D. The client rates left knee pain as 8/10 on the Numerical Rating Scale
Correct Answer: C
Rationale: Clear lung bases indicate no respiratory complications, such as pneumonia, which is critical for discharge readiness. A pulse of 102 and low blood pressure (104/72 mm Hg) suggest possible instability, requiring further evaluation. Low urine output (200 mL/8 hours) indicates potential renal issues, and severe pain (8/10) suggests inadequate pain control, both contraindicating discharge.
The nurse is discharging a client home who has pulmonary tuberculosis. To prevent disease transmission of the client's infection to others, the nurse should recommend that
- A. Common household surfaces get disinfected with a bleach solution.
- B. Your mouth should be covered with a tissue when you cough or laugh and dispose of it in a trash receptacle.
- C. Hand hygiene should be performed frequently with soap and water.
- D. Meals be served on disposable dishes and immediately discarded using gloves.
Correct Answer: B
Rationale: Covering the mouth during coughing or laughing prevents airborne TB transmission. Bleach disinfection, frequent hand hygiene, and disposable dishes are less specific to TB prevention.