Nokea
The nurse is teaching a client with a spinal fusion about body mechanics. Which client statement indicates understanding?
- A. I'll bend at the waist to pick up objects.'
- B. I'll keep my back straight when lifting.'
- C. I'll twist my torso to reach objects.'
- D. I'll carry heavy items close to my chest.'
Correct Answer: B
Rationale: Keeping the back straight during lifting protects the surgical site and maintains spinal alignment.
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The nurse is assessing a client with a recent history of an above-the-knee amputation presenting with phantom limb pain. The nurse anticipates a prescription for
- A. aripiprazole
- B. oxycodone
- C. amitriptyline
- D. hydroxyzine
Correct Answer: C
Rationale: Amitriptyline, a tricyclic antidepressant, is commonly used for neuropathic pain, including phantom limb pain, due to its effects on nerve signaling.
Which statement by a client with acute renal failure indicates understanding of dietary restrictions?
- A. I will avoid oranges.
- B. I can eat unlimited protein.
- C. I should drink less water.
- D. I will eat more spinach.
Correct Answer: A
Rationale: Oranges are high in potassium, which should be avoided in acute renal failure.
The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a:
- A. Low sodium level.
- B. High glucose level.
- C. High calcium level.
- D. Low potassium level.
Correct Answer: D
Rationale: Low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing digoxin's binding to cardiac cells, leading to arrhythmias.
The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
- A. If I limit my fluid intake, I will not have to empty my ostomy pouch as often.
- B. I can place an aspirin tablet in my pouch to decrease odor.
- C. I can usually keep my ostomy pouch on for 3 to 7 days before changing it.
- D. I must use a skin barrier to protect my skin from urine.
- E. I should supply my ostomy pouch of urine when it is full.
Correct Answer: C,D
Rationale: Keeping the pouch on for 3-7 days and using a skin barrier are correct practices. Limiting fluids increases infection risk, aspirin is unsafe, and the last option is unclear but likely a typo for emptying when full, which is correct but not listed as such.
The nurse is monitoring a client who received ketamine for anesthesia induction. Which side effect should the nurse prioritize?
- A. Hypotension.
- B. Respiratory depression.
- C. Vivid dreams or hallucinations.
- D. Bradycardia.
Correct Answer: C
Rationale: Ketamine can cause vivid dreams or hallucinations, which may distress the client during recovery. Monitoring and reassuring the client are critical to manage this psychological side effect.