Nokea
The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include?
- A. Advance a crutch on one side and then advance the opposite foot; repeat on the opposite side.
- B. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side.
- C. Advance both crutches together and then follow by lifting both lower extremities to the level of the crutches.
- D. Advance both crutches together and then follow by lifting both lower extremities past the level of the crutches.
Correct Answer: B
Rationale: The two-point gait involves simultaneous advancement of one crutch and the opposite foot, mimicking natural walking.
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What is the purpose of straining urine in a client with renal calculi?
- A. Detect blood.
- B. Identify stone composition.
- C. Measure urine volume.
- D. Prevent infection.
Correct Answer: B
Rationale: Straining urine captures stones for analysis to determine composition.
A nurse notes that a client has kyphosis and generalized muscle atrophy. Which of the following problems is a priority when the nurse develops a nursing plan of care?
- A. Infection.
- B. Confusion.
- C. Ineffective coughing and deep breathing.
- D. Difficulty chewing solid foods.
Correct Answer: C
Rationale: Kyphosis and muscle atrophy impair chest expansion and cough effectiveness, increasing pneumonia complications. Ineffective coughing and deep breathing is the priority to clear secretions and prevent worsening infection. Infection is already present. Confusion and chewing difficulties are less immediate concerns.
Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will:
- A. Demonstrate appropriate use of analgesics to control pain.
- B. Explain the rationale for eliminating alcohol from the diet.
- C. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months.
- D. Eliminate contact sports from his or her lifestyle.
Correct Answer: B
Rationale: Eliminating alcohol is critical for clients with peptic ulcer disease, as it irritates the gastric mucosa and can exacerbate symptoms. The other options are less directly related to the management of peptic ulcer disease.
A 48-year-old client with cancer has been receiving 10 mg of I.V. morphine while hospitalized. In control, the nurse should administer which of the following doses of oral morphine?
- A. 25 mg.
- B. 30 mg.
- C. 40 mg.
- D. 10 mg.
Correct Answer: B
Rationale: The equianalgesic conversion from 10 mg I.V. morphine to oral morphine (1:3 ratio) is 30 mg, as oral morphine has lower bioavailability due to first-pass metabolism.
A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when his vital signs suddenly change. In addition to notifying the physician, what other action should the nurse take immediately?
- A. Administer oxygen.
- B. Elevate the head of the bed 30 degrees.
- C. Administer a bolus of I.V. fluids.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Sudden vital sign changes post-gastrectomy suggest hypoxia or shock. Administering oxygen addresses potential respiratory compromise, a common postoperative issue, while awaiting physician guidance.