Nokea
The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed first?
- A. A 55-year-old client who is 6 feet tall and weighs 180 lb.
- B. A 75-year-old who lives alone.
- C. A 74-year-old who has periodontal disease with periodontitis.
- D. A 75-year-old who has asthma and uses an inhaler.
Correct Answer: C
Rationale: Periodontal disease increases infection risk due to potential bacterial spread to the prosthesis.
You may also like to solve these questions
The nurse explains to the client that the main reason a back rub is used as therapy to relieve pain is because the massage:
- A. Blocks pain impulses from the spinal cord to the brain.
- B. Blocks pain impulses from the brain to the spinal cord.
- C. Stimulates the release of endorphins.
- D. Distracts the client's focus on the source of the pain.
Correct Answer: C
Rationale: Massage, like a back rub, stimulates endorphin release, which naturally reduces pain perception. It does not block pain impulses directly or act solely as a distraction.
What diet should be implemented for a client who is in the early stages of cirrhosis?
- A. High-calorie, high-carbohydrate.
- B. High-protein, low-fat.
- C. Low-fat, low-protein.
- D. High-carbohydrate, low-sodium.
Correct Answer: A
Rationale: A high-calorie, high-carbohydrate diet (A) supports energy needs in early cirrhosis. High-protein (B) may worsen encephalopathy. Low-fat, low-protein (C) is too restrictive. Low-sodium (D) is relevant for ascites, not early cirrhosis.
A client undergoing a bilateral adrenalectomy has postoperative orders for hydromorphone hydrochloride (Dilaudid) 2 mg to be given subcutaneously every 4 hours as needed for pain. The medication is administered in relatively small doses primarily because it is:
- A. Less likely to cause dependency in small doses.
- B. Less irritating to subcutaneous tissues in small doses.
- C. As potent as most other analgesics in larger doses.
- D. Excreted before accumulating in toxic amounts in the body.
Correct Answer: C
Rationale: Hydromorphone is a potent opioid, effective in small doses, reducing the need for larger doses that increase side effect risks.
Upon assessment of third degree heart block on the monitor, the nurse should first:
- A. Call a code.
- B. Begin cardiopulmonary resuscitation.
- C. Have transcutaneous pacing ready at the bedside.
- D. Prepare for defibrillation.
Correct Answer: C
Rationale: Third-degree heart block may require pacing. Having transcutaneous pacing ready is the first step to manage symptomatic bradycardia.
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate?
- A. Maintaining an upright position.
- B. Restricting the diet to liquids until swallowing improves.
- C. Introducing foods on the unaffected side of the mouth.
- D. Keeping distractions to a minimum.
Correct Answer: B
Rationale: Restricting the diet to liquids increases aspiration risk, as liquids are harder to control. Upright positioning, using the unaffected side, and minimizing distractions reduce aspiration risk.