Nokea
When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following?
- A. The area proximal to the fracture.
- B. The actual fracture site.
- C. The area distal to the fracture.
- D. The opposite extremity for baseline comparison.
Correct Answer: C
Rationale: Assessing distal to the fracture checks for neurovascular compromise, a priority to prevent complications.
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When the nurse enters the client's room, the nurse perceives that the client is staring straight ahead. Which of the following is the best course of action for the nurse to take next?
- A. Hold an interdisciplinary meeting on the client's behalf promptly.
- B. Consult with psychiatry.
- C. Listen to the client and observe the body language.
- D. Address the client by first name upon entering the room.
Correct Answer: C
Rationale: Listening to the client and observing body language allows the nurse to assess the client's condition and needs, considering macular degeneration may cause the client to appear to stare straight ahead due to central vision loss.
Because a client's renal stone was found to be composed of uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications?
- A. Milk, apples, tomatoes, and corn.
- B. Eggs, spinach, dried peas, and gravy.
- C. Salmon, chicken, and asparagus.
- D. Grapes, corn, cereals, and liver.
Correct Answer: A
Rationale: Milk, apples, tomatoes, and corn are low-purine and promote an alkaline-ash diet, suitable for uric acid stone prevention.
The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The nurse should do which of the following? Select all that apply.
- A. Elevate the head of the bed to 50 degrees.
- B. Obtain daily cultures.
- C. Cover with protective dressing.
- D. Reposition the client every 2 hours.
- E. Request an alternating-pressure mattress.
Correct Answer: C,D,E
Rationale: Protective dressings, frequent repositioning, and pressure-relieving mattresses promote healing and prevent worsening of pressure ulcers. High head elevation increases shear, and daily cultures are unnecessary unless infection is suspected.
Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay development of:
- A. Chronic obstructive pulmonary disease.
- B. Pancreatic cancer.
- C. Renal failure.
- D. Cerebrovascular accident.
Correct Answer: C
Rationale: ACE inhibitors protect against renal failure in diabetes by reducing vascular damage and proteinuria.
A client who is recovering from a subtotal gastrectomy experiences dumping syndrome. The client asks the nurse, 'When will I be able to eat three meals a day again like I used to?' Which of the following responses by the nurse is most appropriate?
- A. Eating six meals a day is time-consuming, isn't it?'
- B. You will have to eat six small meals a day for the rest of your life.'
- C. You will be able to tolerate three meals a day before you are discharged.'
- D. Most clients can resume their normal meal patterns in about 6 to 12 months.'
Correct Answer: D
Rationale: Most clients can gradually resume a normal meal pattern (three meals a day) within 6 to 12 months as the body adapts post-gastrectomy, making this the most accurate and supportive response.