Nokea
What should the nurse include in the care plan for a client with a spinal cord injury?
- A. Frequent repositioning.
- B. High-protein diet.
- C. Limited mobility exercises.
- D. Fluid restriction.
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers in clients with spinal cord injuries.
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The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which of the following?
- A. Decreased salivation.
- B. Bradycardia.
- C. Cold intolerance.
- D. Nausea.
Correct Answer: C
Rationale: Cold intolerance is a common symptom of anemia due to reduced oxygen-carrying capacity, and assessing it helps plan supportive care.
The nurse is reviewing a new prescription for amphotericin b. The nurse recognizes that this medication is prescribed to treat
- A. autoimmune infections.
- B. fungal infections.
- C. viral infections.
- D. bacterial infections.
Correct Answer: B
Rationale: Amphotericin B is an antifungal medication used to treat systemic fungal infections. It is not used for autoimmune (A), viral (C), or bacterial (D) infections.
During preadmission testing for same-day surgery, a client states that she has added two cloves of garlic each day to her diet to help control her blood pressure. The nurse should further inquire about which of the following?
- A. The type of surgery the client is having.
- B. What her blood pressure has been running.
- C. The amount of garlic she is eating.
- D. Her preference for the type of anesthesia.
Correct Answer: B
Rationale: Garlic can affect blood pressure and has anticoagulant properties, which may increase bleeding risk during surgery. Inquiring about the client's blood pressure helps assess the impact of garlic on her condition and informs surgical planning. The type of surgery, amount of garlic, or anesthesia preference are less directly relevant to this concern.
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 asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this to monitor for signs of which of the following?
- A. External hemorrhage.
- B. Decreasing level of consciousness.
- C. Laryngeal nerve damage.
- D. Upper airway obstruction.
Correct Answer: C
Rationale: Asking the client to speak monitors for laryngeal nerve damage, which can cause vocal cord paralysis and hoarseness, a potential complication of thyroidectomy.