Nokea
Which area of health teaching is essential to include in the discharge instructions for a client who has undergone a total hip replacement?
- A. Modifying ways of donning clothing
- B. Using special equipment for bathing
- C. Taking vigorous daily walks
- D. Receiving a daily stool softener
Correct Answer: A
Rationale: Modifying clothing application (e.g., avoiding bending or crossing legs) prevents hip dislocation, making it essential for discharge teaching. Vigorous walks are contraindicated, and the other options are less critical.
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The client continues to recover following a below-the-knee amputation. What nursing action should the nurse employ to help prevent the most common complication following leg amputation?
- A. Clean the wound with hydrogen peroxide three times a day
- B. Have the client lie prone several times a day
- C. Ask the client to flex and extend the toes on the remaining leg
- D. Encourage the client to completely empty his/her bladder
Correct Answer: B
Rationale: Lying prone prevents hip flexion contractures, the most common complication post-amputation.
While the client is waiting for the ankle to be X-rayed, which nursing measure is most helpful for relieving the soft-tissue swelling?
- A. Place a heating pad on the ankle.
- B. Apply ice to the ankle.
- C. Exercise the client's foot.
- D. Immobilize the client's foot.
Correct Answer: B
Rationale: Applying ice is the most effective initial measure to reduce soft-tissue swelling by causing vasoconstriction, which decreases blood flow and fluid accumulation in the injured area. Heat may increase swelling, exercise could exacerbate the injury, and immobilization alone does not address swelling as directly.
The child with an SCI is prescribed baclofen 5 mg tid orally to treat muscle spasticity. How many tablets should the nurse administer for one dose if 20-mg tablets are available?
Correct Answer: 0.25
Rationale: 5 mg divided by 20 mg per tablet equals 0.25 tablets per dose.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate (Rheumatrex) therapy?
- A. Constipation
- B. Arrhythmia
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores (stomatitis) are a common adverse effect of methotrexate due to its impact on rapidly dividing cells, like those in the oral mucosa. The other symptoms are less commonly associated.
Which explanation by the nurse is best when the parents ask how their child with Duchenne muscular dystrophy will be treated knowing that the life expectancy is limited?
- A. "Due to your child's cognitive impairment, your child will be unaware of a shortened life."
- B. "We will focus on maximizing your child's abilities and promoting your child's comfort."
- C. "There is not enough known about this disease to know what will happen in the future."
- D. "Nothing is likely to happen for a long time; we'll deal with it when the time comes."
Correct Answer: B
Rationale: Treatment for DMD focuses on maximizing function and comfort to improve quality of life.