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Which instruction should the nurse reinforce to ensure that the exercises are done correctly?
- A. Move your toes toward and away from your head.
- B. Contract and relax your thigh muscles.
- C. The client's effect on the use of the head.
- D. Bend your knee and pull your lower leg upward.
Correct Answer: B
Rationale: Isometric quadriceps-setting exercises involve contracting and relaxing the thigh muscles without joint movement, strengthening the muscle while minimizing stress on the surgical site. The other options describe different movements.
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Which level of participation should the nurse expect when assessing a 9-year-old who has mental retardation with an IQ level of 45?
- A. Able to communicate verbally only with two-letter words
- B. Able to read and comprehend simple written instructions
- C. Able to walk independently and perform a simple skill
- D. Able to perform tasks that require careful manual dexterity
Correct Answer: C
Rationale: An IQ of 45 indicates moderate intellectual disability, allowing independent walking and simple tasks.
The client is taking calcium carbonate (Tums) to help prevent further development of osteoporosis. Which teaching should the nurse implement?
- A. Encourage the client to take Tums with at least eight (8) ounces of water.
- B. Teach the client to take Tums with the breakfast meal only.
- C. Instruct the client to take Tums 30 to 60 minutes before a meal.
- D. Discuss the need to get a monthly serum calcium level.
Correct Answer: A
Rationale: Taking Tums with water ensures proper absorption and prevents GI irritation. Timing with meals is flexible, pre-meal timing is unnecessary, and monthly calcium levels are not routine.
Which nursing instruction about heating pads is essential to include in the client's teaching plan?
- A. Use the lowest setting on the heating pad.
- B. Place the heating pad directly on the skin.
- C. Cover the heating pad with plastic during use.
- D. Apply the heating pad for 2 hours at a time.
Correct Answer: A
Rationale: Using the lowest setting on the heating pad minimizes the risk of burns, especially in older clients with potentially reduced skin sensitivity. Direct skin contact, plastic covers, or prolonged use increase burn risk.
While teaching the client, what can the nurse explain about the purpose for prescribing this medication?
- A. To reduce emotional depression
- B. To relax skeletal muscles
- C. To promote restful sleep
- D. To relieve inflammation
Correct Answer: B
Rationale: Cyclobenzaprine (Flexeril) is a muscle relaxant used to reduce muscle spasms associated with a herniated disk, alleviating pain and improving mobility. It does not primarily address depression, sleep, or inflammation.
The client with DM is admitted with possible osteomyelitis secondary to an ankle wound. The client's ankle is painful, red, swollen, and warm, and the wound is persistently draining. The client's temperature is 102.2°F (39°C). Based on the client's status, which HCP order should the nurse plan to defer until later?
- A. Obtain a culture of the ankle wound.
- B. Administer ceftriaxone 1 g IV q12h.
- C. Apply splint to immobilize the ankle.
- D. Teach on IV antibiotic self-administration.
Correct Answer: D
Rationale: D. The nurse should defer teaching. Pain and an elevated temperature are barriers to learning.