Nokea
Which nursing intervention is most important after the client returns from the myelogram?
- A. Turning off the room's bright lights
- B. Withholding food and fluids for 12 hours
- C. Administering sedatives every 6 hours
- D. Encouraging a high fluid intake
Correct Answer: D
Rationale: A high fluid intake post-myelogram with water-soluble dye helps excrete the contrast, reducing the risk of complications like seizures or renal issues. Other interventions are less critical.
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The nurse is analyzing the serum laboratory report for the client diagnosed with lung cancer that has metastasized to the pelvic bone. Which specific finding should the nurse anticipate?
- A. Elevated calcium
- B. Decreased hemoglobin
- C. Elevated creatinine (SCr)
- D. Elevated creatine kinase (CK)
Correct Answer: A
Rationale: A. Malignant tumors cause hypercalcemia through a variety of mechanisms, one being an increased release of calcium from the bones.
What is the purpose of the continuous passive motion (CPM) machine that the nurse should explain while teaching the client?
- A. A CPM machine is used to strengthen the leg muscles.
- B. A CPM machine is used to relieve foot swelling.
- C. A CPM machine is used to reduce surgical pain.
- D. A CPM machine is used to restore joint function.
Correct Answer: D
Rationale: CPM promotes joint mobility and prevents stiffness post-arthroplasty.
When the nurse observes the client walking, which assessment finding indicates the need for more instruction regarding the use of the cane?
- A. The tip of the cane is covered with a rubber cap.
- B. The client wears athletic shoes with nonskid soles.
- C. The client uses the cane on the painful side.
- D. The client looks straight ahead when walking.
Correct Answer: C
Rationale: The cane should be used on the unaffected side to support the painful hip, distributing weight appropriately. Using it on the painful side reduces its effectiveness, requiring further instruction.
The nurse documents the admission assessment for the client who is to have a left total hip arthroplasty to treat chronic degenerative joint disease. Which statements indicate that the client uses alternative therapies for CA treatment? Select all that apply.
- A. I take ibuprofen every 4 to 6 hours.'
- B. I wear a copper bracelet all the time.'
- C. I take glucosamine sulfate 1000 mg daily.'
- D. I apply special magnets to the hip joint.'
- E. I sleep on the unaffected hip, turning often.'
Correct Answer: B,C,D
Rationale: B. Wearing a copper bracelet is an alternative therapy used by some with CA for pain control and reduction of joint stiffness. C. Taking glucosamine sulfate is an alternative therapy used by some with CA. Glucosamine is taken to modify cartilage structure, but studies supporting this have been inconclusive. D. Using magnets designed for body application is an alternative therapy used by some with CA for pain control and reduction of joint stiffness.
The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
- A. Help the client with a two (2)-day postop amputation put on the prosthesis.
- B. Request the UAP double-check a unit of blood to be hung.
- C. Change the surgical dressing on the client with a Syme's amputation.
- D. Ask the UAP to take the client to the physical therapy department.
Correct Answer: D
Rationale: Transporting a client to PT is within UAP scope. Prosthesis application, blood verification, and dressing changes require nursing judgment.