Nokea
Which intervention is most appropriate for a client with impaired mobility due to a neurological condition?
- A. Encourage bed rest.
- B. Provide assistive devices.
- C. Limit physical therapy.
- D. Restrict fluid intake.
Correct Answer: B
Rationale: Providing assistive devices promotes safe mobility and independence for a client with impaired mobility.
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A client is receiving Pentoxifylline (Trental) for intermittent claudication. The nurse should determine the effectiveness of the drug by asking the client:
- A. If he has improved circulation in the legs
- B. If he can wiggle his toes
- C. If he is urinating more frequently
- D. If he is less dizzy
Correct Answer: A
Rationale: Pentoxifylline improves blood flow by reducing blood viscosity and increasing erythrocyte flexibility, alleviating intermittent claudication. Asking about improved leg circulation (e.g., reduced pain or increased walking distance) assesses its effectiveness. Toe movement, urination, and dizziness are unrelated to its therapeutic action.
The nurse is monitoring a client post-insertion of a nasogastric tube for an intestinal obstruction. Which finding indicates the tube is functioning correctly?
- A. Clear, watery output.
- B. Bright red blood in the drainage.
- C. No output for 12 hours.
- D. Thick, mucus-like drainage.
Correct Answer: A
Rationale: Clear, watery output from a nasogastric tube indicates it is effectively decompressing the intestine by removing fluid and gas. Bright red blood suggests bleeding, no output may indicate a blockage, and thick drainage is not typical. CN: Physiological adaptation; CL: Evaluate
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
- A. Constipation.
- B. Hyperkalemia.
- C. Irregular pulse.
- D. Dysuria.
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, so hyperkalemia (B) is a key adverse effect. Constipation (A), irregular pulse (C), and dysuria (D) are not typical.
In which of the following clients is an autotransfusion contraindicated?
- A. The client who has cancer.
- B. The client who is in danger of cardiac arrest.
- C. The client with a contaminated wound.
- D. The client with a ruptured bowel.
Correct Answer: A,C,D
Rationale: Autotransfusion is contraindicated in cancer (risk of spreading malignant cells), contaminated wounds, or ruptured bowel (risk of infection or bacterial spread). It may be used cautiously in cardiac arrest if no other contraindications exist.
After pituitary surgery, the nurse should assess the client for which of the following?
- A. Urine specific gravity less than 1.010.
- B. Urine output between 1 and 2 L/day.
- C. Blood glucose level higher than 300 mg/dL.
- D. Urine negative for glucose and ketones.
Correct Answer: A
Rationale: Low urine specific gravity (<1.010) may indicate diabetes insipidus, a common complication post-pituitary surgery due to reduced vasopressin.