Nokea
When using crutches, the client should be instructed to bear weight primarily on the:
- A. Axillae
- B. Elbows
- C. Upper arms
- D. Hands
Correct Answer: D
Rationale: Weight should be borne on the hands when using crutches to prevent nerve damage from pressure on the axillae. Elbows and upper arms are not primary weight-bearing areas.
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A client with a history of cirrhosis is admitted with ascites. The nurse should include which of the following in the plan of care?
- A. Administer spironolactone as prescribed.
- B. Restrict sodium intake.
- C. Encourage a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A, B
Rationale: Spironolactone and sodium restriction reduce fluid retention in ascites.
Immediately after the client receives an injection of bupivacaine (Marcaine), he becomes restless and nervous and reports a feeling of impending doom. Which of the following actions by the nurse is appropriate at this time?
- A. Ask the client to talk more about what he is feeling
- B. Reassure the client that it is normal to feel restless before a procedure
- C. Assess the client's vital signs
- D. Administer epinephrine
Correct Answer: C
Rationale: Restlessness, nervousness, and a feeling of impending doom after bupivacaine injection may indicate systemic toxicity or an allergic reaction, requiring immediate vital sign assessment to guide further action. Talking, reassurance, or administering epinephrine without assessment is premature.
A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?
- A. To listen to the fetal heart rate
- B. To startle and awaken the fetus
- C. To stimulate mild contractions
- D. To confirm amniotic fluid amount
Correct Answer: B
Rationale: Fetal acoustic stimulation is used to startle and awaken the fetus, prompting movement to assess fetal heart rate reactivity during a nonstress test. It does not directly measure heart rate, stimulate contractions, or assess amniotic fluid.
You have been asked to teach an inservice class for nurses in your facility about ethics. Which of the following should you consider during the planning of this educational activity?
- A. Planning a way to evaluate the effectiveness of the class by seeing a decrease in the amount of referrals to the facility's Ethics Committee
- B. Establishing educational objectives for the class that reflect the methods and methodology that you will use to present the class content
- C. The need to exclude case studies from the class because this would violate client privacy and confidentiality
- D. Some of the most commonly occurring bioethical concerns including genetic engineering into the course content
Correct Answer: B
Rationale: When planning an educational activity, establishing clear educational objectives is essential to define the content, methods, and expected outcomes of the class, ensuring effective learning.
The nurse is caring for a client with a history of liver cirrhosis who is prescribed lactulose (Cephulac). The nurse should expect the client to experience which of the following effects?
- A. Reduced ascites.
- B. Decreased ammonia levels.
- C. Increased appetite.
- D. Weight loss.
Correct Answer: B
Rationale: Lactulose reduces ammonia levels in cirrhosis by promoting its excretion, preventing hepatic encephalopathy.