Nokea
The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid:
- A. Using a recliner to rest
- B. Resting in supine position
- C. Sitting in a straight chair
- D. Sleeping in right Sim's position
Correct Answer: C
Rationale: Sitting in a straight chair can compress the graft, impairing blood flow, and should be avoided to promote graft patency.
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A client is receiving end-of-life care and tells the nurse that he has not always lived the way he should have or treated his children well. Which of the following responses is the most appropriate?
- A. What kinds of things have you done?'
- B. There are things that you regret.'
- C. I'm sure those things don't matter anymore.'
- D. It's not too late to ask for forgiveness.'
Correct Answer: B
Rationale: Reflecting that the client has regrets (B) is empathetic and opens further discussion without judgment. Asking for details (A), dismissing concerns (C), or suggesting forgiveness (D) may not be appropriate.
The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?
- A. Intravenously
- B. Rectally
- C. Intramuscularly
- D. Into the cerebrospinal fluid
Correct Answer: D
Rationale: Intrathecal administration involves delivering medication directly into the cerebrospinal fluid, typically via a spinal injection, to target the central nervous system effectively.
The nurse observes a 2 1/2-year-old toddler in the waiting room. Based on expected child development, the nurse expects to see the child engaged in which type of play?
- A. playing alone, with no interaction with other children
- B. playing cooperatively in a single-sex group
- C. playing parallel to other children, but not playing together
- D. playing and interacting cooperatively in a mixed-sex group
Correct Answer: C
Rationale: Toddlers (2-3 years) engage in parallel play, playing alongside but not cooperatively with others, due to developing social skills.
The nurse gives a 35-year-old primigravida client a RhoGAM injection in her 27th week of pregnancy. Which of the following client situations requires the nurse to take this action?
- A. Rh-negative mother and Rh-positive father
- B. Rh-negative mother and Rh-negative father
- C. Rh-positive mother and Rh-negative father
- D. Rh-positive mother and Rh-positive father
Correct Answer: A
Rationale: RhoGAM is given to an Rh-negative mother with an Rh-positive father to prevent Rh incompatibility issues in the fetus.
The nurse is caring for a newborn who is on strict intake and output. The used diaper weighs $73.5 \mathrm{gm}$. The diaper's dry weight was $62 \mathrm{gm}$. The newborn's urine output is:
- A. 10 ml
- B. 11.5 ml
- C. 10 gm
- D. 12 gm
Correct Answer: B
Rationale: Urine output is calculated by subtracting dry diaper weight from wet diaper weight: 73.5 gm - 62 gm = 11.5 ml (1 gm = 1 ml for urine).