Nokea
The nurse is teaching a client with a right-leg fracture who has a prescription for partial weight-bearing status how to ambulate with crutches. The nurse determines that the client demonstrates compliance with this restriction to prevent complications of the fracture if the client follows which direction?
- A. Allows the right foot to only touch the floor
- B. Does not bear any weight on the right leg/foot
- C. Puts 30 \% to 50 \% of the weight on the right leg/foot
- D. Puts 60 \% to 80 \% of the weight on the right leg/foot
Correct Answer: C
Rationale: The client who has partial weight-bearing status is allowed to place 30 \% to 50 \% of the body weight on the affected limb. Touchdown weight-bearing allows the client to let the limb touch the floor but not to bear weight. Nonweight-bearing status does not allow the client to let the limb touch the floor. There is no classification for 60 \% to 80 \% weight-bearing status. Full weightbearing status involves placing full weight on the limb.
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The nurse is providing instructions to a client and family regarding home care after left-eye cataract removal. The nurse tells the client and family about assuming which position during the postoperative period?
- A. Sleep only on the left side.
- B. Sleep on the right side or the back.
- C. Bend below the waist as often as you are able.
- D. Lower the head between the knees three times a day.
Correct Answer: B
Rationale: After cataract surgery, the client is informed to sleep on the nonoperative side or his or her back. The client should not sleep on the operative side to prevent the development of edema. The client should also avoid bending below the level of the waist or lowering the head because these actions will increase intraocular pressure.
The nurse is planning dietary counseling for the client with chronic heart failure taking triamterene. The nurse plans to include which item in a list of foods that are acceptable?
- A. Bananas
- B. Oranges
- C. Baked potato
- D. Canned pears
Correct Answer: D
Rationale: Triamterene is a potassium-retaining diuretic, so high-potassium foods like bananas, oranges, and potatoes should be avoided. Canned pears are lower in potassium, making them acceptable.
The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position?
- A. Sit bolt upright in bed with the arms crossed over the chest.
- B. Lie on the side with the head of the bed at a 45-degree angle.
- C. Sit in a reclining chair tilted slightly back with the feet elevated.
- D. Sit on the edge of the bed with the arms leaning on an overbed table.
Correct Answer: D
Rationale: Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Sitting bolt upright with arms folded across the chest restricts the movement of the anterior and posterior walls of the lung, and side-lying with the head of bed raised to a 45-degree position restricts the expansion of the lateral wall of the lung. Option 3 restricts posterior lung expansion.
Dipyridamole has been prescribed for the client who underwent a valve replacement, and the nurse has provided teaching to the client about the medication. Which statement indicates that the client understands the medication instructions?
- A. This medication will prevent a stroke.
- B. This medication will prevent a heart attack.
- C. This medicine will protect my artificial heart valve.
- D. This medication will help me keep my blood pressure down.
Correct Answer: C
Rationale: Dipyridamole is an antiplatelet medication. It may be administered in combination with warfarin sodium to protect the client's artificial heart valves. Dipyridamole does not prevent stroke or heart attacks. It is an antiplatelet medication rather than an antihypertensive.
The nurse is providing education at a senior center. Which of the following measures will the nurse say is most effective in attaining normal blood pressure in a client with hypertension?
- A. eating red meat daily
- B. increasing potassium and calcium intake
- C. increasing fluid intake
- D. decreasing sodium intake
Correct Answer: D
Rationale: Decreasing sodium intake is the most effective dietary measure to manage hypertension, as sodium increases blood pressure. Red meat (A) may worsen it, potassium/calcium (B) is supportive but less impactful, and fluid intake (C) is not directly related.