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Which information should the nurse include when performing discharge teaching with a client who had an anterolateral approach for a total hip replacement? Select all that apply.
- A. Avoid turning the toes or knee outward.
- B. Use an abduction pillow between the legs when in bed.
- C. Use an elevated toilet seat and shower chair.
- D. Do not extend the operative leg backwards.
- E. Restrict motion for 2 weeks after surgery.
Correct Answer: A,B,C,D
Rationale: These measures prevent dislocation and promote recovery. Motion is encouraged, not restricted, to aid rehabilitation.
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The nurse is planning to give preoperative instructions to a client who will be undergoing rhinoplasty. Which of the following instructions should be included:
- A. After surgery, nasal packing will be in place for 7 to 10 days.
- B. Normal saline nose drops will need to be administered preoperatively.
- C. The results of the surgery will be immediately obvious postoperatively.
- D. Aspirin-containing medications should not be taken for 2 weeks before surgery.
Correct Answer: D
Rationale: Aspirin can increase bleeding risk, so it should be avoided for 2 weeks before surgery. Nasal packing is typically removed within 1–3 days. Saline drops are not routinely required preoperatively. Surgical results may take weeks to months to be fully apparent due to swelling.
A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be:
- A. Administer epinephrine
- B. Inform the physician
- C. Administer oxygen
- D. Inform the client that the procedure is almost over
Correct Answer: B
Rationale: Nausea, tingling, and dyspnea during an arteriogram suggest a possible allergic reaction to the contrast dye or other complications (e.g., vasovagal response). The nurse should immediately inform the physician to evaluate and manage the situation. Administering epinephrine or oxygen requires a physician's order, and reassuring the client is inappropriate until the issue is addressed.
Which of the following will the nurse observe in the ictal phase of a generalized tonic-clonic seizure?
- A. Linking in one extremity that spreads gradually to adjacent areas.
- B. Vacant staring and abruptly ceasing all activity.
- C. Facial grimaces, patting motions, and lip smacking.
- D. Loss of consciousness, body stiffening, and violent muscle contractions.
Correct Answer: D
Rationale: The ictal phase of a generalized tonic-clonic seizure is characterized by loss of consciousness, body stiffening (tonic phase), and violent muscle contractions (clonic phase). The other options describe focal or absence seizures.
Which of the following interventions will be most effective in improving transcultural communications with the client?
- A. Use touch to show concern and caring for the client.
- B. Focus attention on verbal communication skills only.
- C. Establish a rapport and listen to their concerns.
- D. Maintain eye contact at all times.
Correct Answer: C
Rationale: Establishing rapport and listening to concerns fosters trust and understanding, which are essential for effective transcultural communication.
The nurse is planning care for a client with severe postoperative pain. There is an order for 10 mg MSO4. Which of the following should the nurse do first?
- A. Obtain an intravenous infusion system.
- B. Prepare the medication for administration.
- C. Contact the Pharmacy Department.
- D. Contact the physician that ordered the medication.
Correct Answer: A
Rationale: MSO4 (morphine sulfate) is typically given IV for severe pain. Obtaining an IV infusion system ensures the medication can be administered safely and effectively.