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What should be included in Mr. Ross’s plan of care during radiation therapy if he complains of weakness and lethargy?
- A. Encouraging him to rest more than usual
- B. Monitoring his intake and output
- C. Helping him to accept his condition
- D. Checking his blood pressure daily
Correct Answer: A
Rationale: Rest conserves energy and aids recovery during radiation therapy.
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A client had a total hip arthroplasty. Which of the following prescriptions should the nurse verify with the provider?
- A. Administer enoxaparin 30 mg subcutaneously every 12 hr
- B. Place a wedge or pillow between the client's legs when turning.
- C. Instruct the client to restrict flexion of the hip past 120°.
- D. Encourage the client to perform foot and calf exercises every 2 hr
Correct Answer: C
Rationale: The correct answer is C because restricting flexion of the hip past 120° is crucial to prevent dislocation of the prosthetic hip joint post-operatively. Excessive flexion can lead to instability and potential complications. The other options are important but do not directly relate to the risk of hip dislocation. Administering enoxaparin helps prevent blood clots, using a wedge or pillow between the legs promotes proper alignment and comfort, and performing foot and calf exercises aids in preventing blood clots as well. However, restricting hip flexion is the most critical for the client's safety and optimal recovery after a total hip arthroplasty.
A 55-year-old smoker who is normally in good health reports having had a bad cough for the past 3 weeks. He does not have crackles, rhonchi, or discolored blood-tinged sputum. What would you expect his physician to rule out?
- A. Asthma.
- B. Pneumonia.
- C. The flu.
- D. Lung cancer.
Correct Answer: D
Rationale: Persistent cough in smokers raises suspicion for lung cancer.
To prepare a patient on the unit for a bronchoscopic procedure, the medical-surgical nurse administers an IV sedative. The nurse then instructs the licensed practical nurse to
- A. educate the patient about the procedure.
- B. give the patient small sips of water only.
- C. measure the patient's blood pressure and heart rate.
- D. take the patient to the bathroom one more time.
Correct Answer: D
Rationale: Emptying the bladder before the procedure is important for comfort and safety.
What is the main drawback of the botulism antitoxin that the nurse should be aware of?
- A. It causes 9% hypersensitivity.
- B. It requires monthly booster dosages.
- C. It is not available from the CDC.
- D. It is not available as a pre-exposure vaccine.
Correct Answer: D
Rationale: The correct answer is D because botulism antitoxin is not available as a preventive vaccine.
Paralytic ileus may occur as a postoperative complication. Which of the following patients would you be most concerned about the development of paralytic ileus?
- A. Kim, a 27-year-old postlaparoscopic appendectomy.
- B. Joyce, a 39-year-old post–open right hemicolectomy.
- C. Nancy, a 56-year-old postmediastinoscopy.
- D. John, a 47-year-old post–total joint replacement.
Correct Answer: B
Rationale: Paralytic ileus is more common after abdominal surgeries, particularly those involving bowel manipulation, such as an open right hemicolectomy. Joyce is at the highest risk due to the nature of her surgery.