Nokea
When implementing the care plan, the nurse should encourage the major intake of fluids at which time of the day?
- A. Before bedtime
- B. Early evening
- C. In the morning
- D. Midafternoon
Correct Answer: C
Rationale: Encouraging fluid intake in the morning promotes hydration throughout the day, aiding uric acid excretion to prevent kidney stones in gout. Bedtime intake may disrupt sleep due to urination.
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A young adult is discharged to home with crutches. Which exercise should the nurse teach the client in order to strengthen the hand muscles for crutch walking?
- A. Pushing the buttocks up off the mattress
- B. Pulling the body up, using an overhead trapeze
- C. Raising the legs straight up and down
- D. Squeezing a rubber ball in each hand
Correct Answer: D
Rationale: Squeezing a rubber ball strengthens hand muscles, essential for gripping crutches during walking.
Which assessment finding warrants immediate action by the nurse when a client is in Buck's traction?
- A. The traction weights are hanging above the floor.
- B. The leg is in line with the pull of the traction.
- C. The right is about is to be the two.
- D. The rope is in the groove of the traction pulley.
Correct Answer: A
Rationale: Traction weights must hang freely to maintain proper pull. If they are above the floor (e.g., resting on something), the traction is ineffective, requiring immediate correction to ensure proper alignment and healing.
The Muslim client practicing Islam is hospitalized following surgical repair of a hip fracture. The client informs the nurse about wishing to observe Ramadan, which is occurring now. Which statement by the nurse is respectful of the client's faith beliefs?
- A. I'm going to uncover your hip and leg now to check the incision and your pulses.'
- B. A dietitian helps to plan your meals so that meat and dairy products are not together.'
- C. I've asked that physical therapy be postponed until around 3 p.m., when Ramadan ends.'
- D. I should let the care team know not to bring food or beverages from sunrise to sunset.'
Correct Answer: D
Rationale: D. During the month of Ramadan, those of the Islamic faith do not eat or drink from sunrise to sunset.
The clinic nurse completed teaching the client with a rotator cuff tear who is being treated conservatively. Which client statement indicates that further teaching is needed?
- A. I received a corticosteroid injection in my shoulder to reduce the inflammation and pain.'
- B. Now that the pain is controlled, I can do progressive stretching and strengthening exercises.'
- C. I will continue to take ibuprofen for pain control, but I should take it with food.'
- D. I will need an open acromioplasty to repair the torn cuff after the swelling is reduced.'
Correct Answer: D
Rationale: D. Conservative treatment for a rotator cuff tear typically involves non-surgical methods like corticosteroid injections, physical therapy, and NSAIDs. An open acromioplasty is a surgical procedure and not part of conservative management, indicating a misunderstanding by the client.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate therapy?
- A. Constipation
- B. Dry mouth
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores are a common side effect of methotrexate due to its effect on mucosal cells.