Nokea
When teaching the diabetic client about foot care, the nurse should instruct the client to do which of the following?
- A. Avoid going barefoot.
- B. Buy shoes a half size larger.
- C. Cut toenails at angles.
- D. Use heating pads for sore feet.
Correct Answer: A
Rationale: Diabetic clients should avoid going barefoot to prevent foot injuries, which can lead to serious complications due to poor healing and neuropathy.
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For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
- A. Ensure a liberal fluid intake.
- B. Provide an alkaline-ash diet.
- C. Prevent constipation.
- D. Enrich the client's diet with dairy products.
Correct Answer: A
Rationale: Liberal fluid intake promotes calcium excretion through urine, preventing complications like kidney stones or hypercalcemia.
Ergotamine tartrate (Gynergen) is prescribed for a client's migraine headaches. The client's report of which of the following indicates effectiveness?
- A. Prevention of the migraine.
- B. Reduced severity of the developing migraine.
- C. Relief from the sleeplessness experienced in the past after a migraine.
- D. Relief from the vision problems experienced in the past after a migraine.
Correct Answer: B
Rationale: Ergotamine reduces the severity of developing migraines by constricting cranial blood vessels. It is not primarily preventive or used for post-migraine sleeplessness or vision issues.
The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply.
- A. Monitoring vital signs once a shift.
- B. Weighing the client daily.
- C. Changing the central venous line dressing daily.
- D. Monitoring the I.V. infusion rate hourly.
- E. Taping all I.V. tubing connections securely.
Correct Answer: B,C,D,E
Rationale: For a client on TPN, daily weight monitoring (B), daily dressing changes (C), hourly infusion rate checks (D), and securing tubing connections (E) are critical to prevent complications like infection or fluid imbalance. Vital signs once a shift (A) is insufficient; more frequent monitoring is needed. CN: Pharmacological and parenteral therapies; CL: Create
A client with rheumatoid arthritis is experiencing fatigue. Which nursing intervention is most appropriate?
- A. Encourage high-intensity exercise.
- B. Plan rest periods throughout the day.
- C. Increase carbohydrate intake.
- D. Limit fluid intake to reduce swelling.
Correct Answer: B
Rationale: Planning rest periods conserves energy and reduces fatigue in rheumatoid arthritis.
Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as ordered. The nurse should do which of the following first?
- A. Ask the client's wife to assist with the daily fluid intake to at least 2,500 mL.
- B. Respect the client's wishes and turn the client from side-to-side more frequently.
- C. Assess the client's reasons for refusing to deep breathe and cough.
- D. Explain the risks of not expanding the lungs and why the exercise is important.
Correct Answer: C
Rationale: Assessing the client's reasons for refusal identifies barriers (e.g., pain, fear), allowing tailored interventions to encourage compliance with deep-breathing exercises.