Nokea
Which fluid is best for a client with renal calculi?
- A. Cranberry juice.
- B. Cola.
- C. Water.
- D. Milk.
Correct Answer: C
Rationale: Water increases urine volume, reducing stone formation risk.
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The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include?
- A. Advance a crutch on one side and then advance the opposite foot; repeat on the opposite side.
- B. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side.
- C. Advance both crutches together and then follow by lifting both lower extremities to the level of the crutches.
- D. Advance both crutches together and then follow by lifting both lower extremities past the level of the crutches.
Correct Answer: B
Rationale: The two-point gait involves simultaneous advancement of one crutch and the opposite foot, mimicking natural walking.
A client is about to undergo bone marrow aspiration of the sternum. Which of the following statements should the nurse include to provide information to the client about what the client will feel during the procedure?
- A. You may feel a warm solution being wiped over your entire front from your neck down to your navel and out to your shoulders.'
- B. You will not feel the local anesthetic being applied because it will be sprayed on.'
- C. You will feel a pulling type of discomfort for a few seconds.'
- D. After the needle is removed, you will feel a bandage being applied around your chest.'
Correct Answer: C
Rationale: During sternal bone marrow aspiration, the client may feel a brief pulling or pressure sensation as the marrow is aspirated. The antiseptic solution is not applied over such a large area, local anesthetic is injected (not sprayed), and a bandage is applied to the site, not around the chest.
What should the nurse teach a client with Parkinson's about fall prevention?
- A. Use a walker if unsteady.
- B. Avoid all physical activity.
- C. Wear tight shoes.
- D. Keep lights dimmed.
Correct Answer: A
Rationale: Using a walker if unsteady helps prevent falls in Parkinson's patients with gait instability.
A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine via PCA 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should:
- A. Discontinue the PCA pump.
- B. Administer oxygen.
- C. Take the client's blood pressure.
- D. Assist the client back to bed.
Correct Answer: C
Rationale: Dizziness after morphine suggests possible hypotension. Taking the blood pressure identifies the cause and guides further action, such as fluid administration or repositioning.
The nurse is discussing infiltration with a group of students. It would be appropriate for the nurse to describe this complication as
- A. a vesicant drug entering into intradermal tissue.
- B. a non-vesicant drug entering subcutaneous tissue.
- C. a vesicant drug entering into subcutaneous tissue.
- D. a vesicant drug entering the muscle by injection.
Correct Answer: B
Rationale: Infiltration involves non-vesicant fluid leaking into subcutaneous tissue, causing swelling and discomfort.