Nokea
The nurse is teaching a client post-appendectomy about activity restrictions. Which instruction is most appropriate?
- A. Avoid lifting more than 10 pounds for 4–6 weeks.
- B. Resume full activity within 1 week.
- C. Avoid walking for at least 2 weeks.
- D. Perform sit-ups to strengthen abdominal muscles.
Correct Answer: A
Rationale: Avoiding lifting more than 10 pounds for 4–6 weeks prevents strain on the surgical site post-appendectomy. Resuming full activity too soon, avoiding walking, or doing sit-ups could impair healing. CN: Physiological adaptation; CL: Synthesize
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To help minimize the risk of postoperative respiratory complications after a hypophysectomy, during preoperative teaching, the nurse should instruct the client how to:
- A. Use blow bottles.
- B. Turn in bed.
- C. Take deep breaths.
- D. Cough.
Correct Answer: C
Rationale: Deep breathing exercises post-hypophysectomy help expand lungs and prevent atelectasis, reducing respiratory complications.
Which outcome is realistic for a client with a chronic neurological condition?
- A. Complete symptom reversal.
- B. Maintain functional ability.
- C. Eliminate all medications.
- D. Prevent all complications.
Correct Answer: B
Rationale: Maintaining functional ability is a realistic goal for managing chronic neurological conditions.
After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching?
- A. To align injured bones.
- B. To provide long-term pull.
- C. To apply 25 lb of traction.
- D. To pull weight with a boot.
Correct Answer: C
Rationale: The amount of traction (e.g., 25 lb) is specific to the injury and not a general purpose, indicating a misunderstanding.
A client with a total hip replacement asks about resuming sexual activity. Which response by the nurse is most appropriate?
- A. Wait at least 3 months post-surgery.'
- B. Avoid positions that flex the hip beyond 90 degrees.'
- C. Resume when you feel no pain.'
- D. Use a soft mattress for comfort.'
Correct Answer: B
Rationale: Avoiding excessive hip flexion prevents dislocation during sexual activity post-hip replacement.
On the day of surgery, a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client's 6 a.m. glucose level is 300 mg/dL. The nurse should:
- A. Withhold all medications as ordered.
- B. Administer the insulin dose dictated by the sliding scale.
- C. Call the physician for specific orders based on the glucose level.
- D. Notify the surgery department.
Correct Answer: C
Rationale: A glucose level of 300 mg/dL indicates significant hyperglycemia, which poses risks during surgery. Calling the physician for specific orders ensures appropriate insulin administration while adhering to NPO and surgical protocols.