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: Morning fluid intake promotes hydration and uric acid excretion throughout the day.
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Which description by the nurse most accurately states the purpose of halo-cervical traction?
- A. It restricts neck movement but enables physical activity.
- B. It allows head movement while immobilizing the spine.
- C. It accelerates healing by facilitating physical therapy.
- D. It promotes faster bone repair within a shorter time span.
Correct Answer: A
Rationale: Halo-cervical traction immobilizes the cervical spine to promote healing while allowing some physical activity (e.g., walking), unlike other options that inaccurately describe its function.
The client is scheduled for a magnetic resonance imaging (MRI) scan. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Prepare the client by removing all metal objects.
- B. Inject the contrast into the intravenous site.
- C. Administer a sedative to the client to decrease anxiety.
- D. Explain why the client cannot have any breakfast.
Correct Answer: A
Rationale: Removing metal objects is a safe UAP task, ensuring MRI safety. Contrast injection, sedation, and explanations require nursing judgment.
The nurse correctly instructs the client to avoid which type of fluid?
- A. Milk
- B. Alcohol
- C. Cranberry juice
- D. Carbonated drinks
Correct Answer: B
Rationale: Alcohol, especially beer, increases uric acid production and reduces its excretion, worsening gout. Milk, cranberry juice, and carbonated drinks are generally safe unless otherwise contraindicated.
The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement?
- A. Monitor the continuous passive motion machine.
- B. Apply thigh-high TED hose bilaterally.
- C. Place the abductor pillow between the legs.
- D. Encourage the family to perform ADLs for the client.
Correct Answer: A
Rationale: Monitoring the CPM machine ensures proper knee flexion/extension post-TKR. TED hose are standard, abductor pillows are for THR, and family ADL performance hinders independence.
The nurse explains that the primary reason for the client's increased risk for altered skin integrity due to a T12 SCI is which factor?
- A. The inability to perceive extremes in temperature leading to burns
- B. The inability to feel skin irritation such as wrinkled linens or clothing
- C. The increased likelihood of bowel and bladder dysfunction and skin irritation
- D. The circulatory changes that cause vasoconstriction and decreased blood supply
Correct Answer: B
Rationale: Loss of sensation below T12 prevents the perception of skin irritants, increasing the risk of pressure ulcers.