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The nurse is teaching a client with osteoarthritis about assistive devices. Which device is most appropriate for ambulation?
- A. Standard cane.
- B. Wheelchair.
- C. Four-wheeled walker.
- D. Crutches.
Correct Answer: A
Rationale: A standard cane provides support and stability for clients with osteoarthritis during ambulation.
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A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first?
- A. Initiate gastric lavage.
- B. Maintain body temperature.
- C. Administer 100% oxygen by mask.
- D. Obtain a psychiatric referral.
Correct Answer: C
Rationale: Administering 100% oxygen displaces carbon monoxide from hemoglobin, the priority in poisoning. Gastric lavage, temperature maintenance, and psychiatric referrals are secondary.
Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time?
- A. Teaching how to prevent hip flexion.
- B. Demonstrating coughing and deep-breathing techniques.
- C. Showing the client what an actual hip prosthesis looks like.
- D. Assessing the client's fears about the procedure.
Correct Answer: A
Rationale: Preventing hip flexion is critical to avoid dislocation post-surgery.
Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
The nurse is teaching the client about deep-breathing techniques. Which of the following client statements indicates the need for additional education?
- A. œI will use my incentive spirometer every hour while I'm awake.'
- B. œI should place my hands lightly over my lower ribs and upper abdomen.'
- C. œI should get into a comfortable position before doing my breathing exercises.'
- D. œI should take four deep breaths and then cough deeply from the lungs.'
Correct Answer: D
Rationale: Taking four deep breaths before coughing is incorrect, as the client should perform deep breaths and cough in a sequence, typically 2-3 breaths followed by a cough, to prevent atelectasis effectively.
A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time?
- A. Report hematuria to the physician.
- B. Strain the urine carefully.
- C. Administer meperidine (Demerol) every 3 hours.
- D. Apply warm compresses to the flank area.
Correct Answer: B
Rationale: Straining urine is critical when pain becomes intermittent, indicating possible stone passage, to confirm stone expulsion and guide treatment.