Nokea
The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following:
- A. Turning every 2 hours
- B. Passive and active range-of-motion exercises
- C. Use of thromboembolic disease support (TED) hose
- D. Maintaining the client in the supine position
Correct Answer: D
Rationale: Maintaining the client in the supine position is not recommended, as it promotes stasis and pressure ulcers. Turning every 2 hours, range-of-motion exercises, and TED hose prevent complications like thrombophlebitis and skin breakdown during bed rest.
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The nurse is caring for a client receiving mechanical ventilation receiving fentanyl and midazolam. Which of the following assessment findings would indicate fentanyl toxicity?
- A. constricted pupils
- B. hypertension
- C. coarse Tremors
- D. diarrhea
Correct Answer: A
Rationale: Constricted pupils (miosis) are a hallmark of opioid toxicity, including fentanyl, due to its effects on the central nervous system.
Which of the following should lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?
- A. Acute respiratory distress syndrome.
- B. Migraine-like headaches.
- C. Numbness in the right leg.
- D. Muscle spasms in the right thigh.
Correct Answer: A
Rationale: Fat embolism commonly presents with acute respiratory distress, a life-threatening complication of femoral fractures.
A 36-year-old female is complaining of increased vaginal dryness during sexual intercourse. She has received chemotherapy in the past and has menopausal symptoms due to ovarian suppression. An appropriate nursing intervention would be to instruct the client on the use of:
- A. Vaginal dilators.
- B. Nightly douches.
- C. Water-soluble vaginal lubricants.
- D. Relaxation techniques.
Correct Answer: C
Rationale: Water-soluble vaginal lubricants are effective for managing vaginal dryness caused by chemotherapy-induced ovarian suppression, improving comfort during intercourse.
The nurse teaches the client with an ileal conduit measures to prevent a urinary loss. Which of the following measures would be most effective?
- A. Avoid people with respiratory tract infections.
- B. Maintain a daily fluid intake of 2,000 to 3,000 mL.
- C. Use sterile technique to change the appliance.
- D. Irrigate the stoma daily.
Correct Answer: B
Rationale: Maintaining high fluid intake (2,000-3,000 mL) prevents urinary stasis and infection, the most effective measure for reducing urinary loss risk.
Which information should the nurse include when developing a teaching plan for a client newly diagnosed with type 2 diabetes mellitus. Select all that apply.
- A. A major risk factor for complications is obesity and central abdominal obesity.
- B. Supplemental insulin is mandatory for controlling the disease.
- C. Exercise increases insulin resistance.
- D. The primary nutritional source requiring monitoring in the diet is carbohydrates.
- E. Annual eye and foot examinations are recommended by the American Diabetes Association (ADA).
Correct Answer: A,D,E
Rationale: Obesity, especially central, is a major risk factor for complications. Carbohydrates require monitoring to manage blood glucose. Annual eye and foot exams are recommended. Insulin is not mandatory for type 2 diabetes, and exercise decreases insulin resistance.