Nokea
The nurse should turn the client on bed rest every 2 hours to prevent the development of pressure ulcers. In addition, the nurse should:
- A. Have the client walk at least twice a day
- B. Insert an indwelling urinary catheter
- C. Monitor serum albumin
- D. Monitor the white blood cell count
Correct Answer: C
Rationale: Monitoring serum albumin assesses nutritional status, which is critical for skin integrity and preventing pressure ulcers. Walking is contraindicated for bed rest, catheters increase infection risk, and white blood cell count is less relevant.
You may also like to solve these questions
The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is:
- A. Relief from spasms of the diaphragm.
- B. Relaxation of smooth muscles in the bronchioles.
- C. Efficient pulmonary circulation.
- D. Stimulation of the medullary respiratory center.
Correct Answer: B
Rationale: Aminophylline, a bronchodilator, is effective when it relaxes bronchial smooth muscles, improving airflow in emphysema.
A client with a history of chronic kidney disease is admitted with hyperphosphatemia. The nurse should expect to administer which of the following medications?
- A. Calcium carbonate.
- B. Ferrous sulfate.
- C. Vitamin D.
- D. Potassium chloride.
Correct Answer: A
Rationale: Calcium carbonate binds phosphate in the gut to manage hyperphosphatemia.
The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate?
- A. Fish
- B. Dog
- C. Cat
- D. Bird
Correct Answer: A
Rationale: Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold.
The nurse is caring for a client who has just undergone a lumbar puncture. Which of the following interventions is most appropriate in the immediate post-procedure period?
- A. Encourage ambulation to prevent stiffness.
- B. Keep the client flat for 4-6 hours.
- C. Administer oral fluids immediately.
- D. Apply heat to the puncture site.
Correct Answer: B
Rationale: Keeping the client flat for 4-6 hours post-lumbar puncture reduces the risk of spinal headache due to cerebrospinal fluid leakage.
You are caring for a postoperative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client?
- A. A cleansing enema
- B. A retention enema
- C. A return-flow enema
- D. A laxative
Correct Answer: C
Rationale: A return-flow enema is used to relieve gas and distention by introducing and withdrawing fluid to stimulate gas expulsion.