Nokea
The nurse is teaching an older adult client with a history of heat exhaustion. Which of the following statements by the client indicates a need for further teaching?
- A. I should take a cool shower after being outdoors in very hot weather.
- B. I can place ice packs on my neck, chest, and stomach after being outdoors in the heat.
- C. I should wear lightweight, light-colored, and loose-fitting clothing when working outside on very hot days.
- D. I should consume water and take my salt tablets when I am outside gardening on very hot days.
Correct Answer: B
Rationale: Using ice packs can cause vasoconstriction or tissue damage and is not recommended for heat exhaustion. Cool showers (A), appropriate clothing (C), and hydration (D) are correct, but salt tablets are unnecessary with adequate diet and hydration.
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A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?
- A. Increase daily fluid intake to at least 2 to 3 L.
- B. Strain urine at home regularly.
- C. Eliminate dairy products from the diet.
- D. Follow measures to alkalinize the urine.
Correct Answer: A,B
Rationale: High fluid intake (2-3 L) prevents stone recurrence, and straining urine monitors for stone passage. Dairy restriction or urine alkalinization depends on stone type.
The nurse is preparing to administer a scheduled intramuscular injection to an apprehensive 4 year old child. Which therapeutic action should the nurse take?
- A. Draw a "magic circle" on the area before the injection.
- B. Have another nurse hold down the child.
- C. Apply EMLA cream to the area immediately before the injection.
- D. Administer the medication right after the child's nap.
Correct Answer: D
Rationale: Administering after a nap can reduce anxiety and discomfort in a child, as they are likely to be calmer.
A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do?
- A. Put the tablet under the tongue until it is dissolved.
- B. Swallow the tablet with 120 mL of water.
- C. Chew the tablet until it is dissolved.
- D. Place the tablet between his cheek and gums.
Correct Answer: A
Rationale: Sublingual nitroglycerin is administered under the tongue for rapid absorption to relieve chest pain. Other methods (swallowing, chewing, or buccal placement) are incorrect for this medication.
The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should:
- A. Use a fluorescent light source to assess the skin.
- B. L rescued the skin only when the Braden score is above 12.
- C. Look for skin color that is darker than the surrounding tissue.
- D. Avoid touching the skin during inspection.
Correct Answer: C
Rationale: In dark skin, Stage I pressure ulcers appear as darker areas compared to surrounding tissue, due to persistent redness or discoloration.
Following a total hip replacement, the nurse should position the client in which of the following ways?
- A. Place weights alongside of the affected extremity to keep the extremity from rotating.
- B. Elevate both feet on two pillows.
- C. Keep the lower extremities adducted by use of an immobilization binder around both legs.
- D. Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs.
Correct Answer: D
Rationale: Slight abduction prevents dislocation by maintaining proper hip alignment.