Nokea
Which of the following actions by the client indicates an understanding of the teaching?
- A. Stepping with his affected leg first when going up stairs
- B. Moving both crutches with the stronger leg forward first
- C. Supporting his body weight while leaning on the axillary crutch pads
- D. Positioning both hands on the grips with his elbows slightly flexed
Correct Answer: D
Rationale: Proper hand positioning ensures effective crutch use.
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Which of the following instructions should the nurse include?
- A. Monitor for weight loss
- B. Increase dietary calcium.
- C. Take on an empty stomach.
- D. Schedule dosage at bedtime
Correct Answer: B
Rationale: The correct answer is B: Increase dietary calcium. This instruction is important for a patient likely prescribed with a medication that can deplete calcium levels. Calcium is essential for bone health and overall well-being. Monitoring weight loss (A) is important but not directly related to the medication's side effects. Taking on an empty stomach (C) or at bedtime (D) may be specific to certain medications, but not universally applicable.
Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure
- B. Compare the client's current weight with preprocedural weight
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedural weight. This is the most appropriate action to evaluate the effectiveness of the procedure because changes in weight can indicate fluid retention or loss, which are common outcomes of many procedures. This comparison helps assess if the procedure had the desired effect on the client's fluid status.
Examine for leakage at the site of the procedure (A) is not the best action to evaluate the procedure's effectiveness as leakage may not always correlate with the overall success of the procedure. Confirming that the client is able to urinate (C) is important but may not directly indicate the effectiveness of the procedure. Checking the client's serum albumin levels (D) is relevant for assessing nutritional status but may not directly evaluate the procedure's effectiveness.
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
- A. Perform suctioning
- B. Assess for urinary retention.
- C. Assess blood pressure every 15 min
- D. Withhold pain medication for headache until other manifestations resolve.
- E. Place client in supine position
- F. Administer nifedipine.
Correct Answer:
Rationale: Rationales provided within the question context.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
- A. Initiate continuous bladder irrigation.
- B. Administer a fluid bolus
- C. Clamp the catheter tubing for 30 min.
- D. Obtain a urine specimen for culture and sensitive
Correct Answer: B
Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (D) is important, but addressing the dehydration issue takes priority.
The client is at risk for developing ------- and--------
- A. Hypoglycemia
- B. bronchopulmonary dysplasia
- C. transient tachypnea of the newborn
- D. Tachycardia
Correct Answer: A, C
Rationale: The correct answer is A and C. Hypoglycemia and transient tachypnea of the newborn are common risks for newborns. Hypoglycemia can occur due to immature liver function, while transient tachypnea results from retained lung fluid. The other choices are incorrect because bronchopulmonary dysplasia is a chronic lung condition seen in premature infants, and tachycardia is a symptom of various conditions but not typically a primary risk for newborns.