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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.
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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.
Which of the following actions should the nurse include in the plan of care?
- A. Give cromolyn nebulized solution every 8 hr
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Apply a warm compress to the operative site once daily
- D. Offer small amounts of clear liquids 6 hr following surgery.
Correct Answer: B
Rationale: The correct answer is B because administering analgesics on a scheduled basis for the first 24 hours post-surgery helps manage pain effectively. Pain management is crucial for patient comfort and promotes early mobilization. Choice A is incorrect because cromolyn nebulized solution is not typically used post-operatively. Choice C is incorrect as applying a warm compress once daily may not provide adequate pain relief. Choice D is incorrect as clear liquids are usually started slowly to prevent nausea and vomiting, not 6 hours post-surgery.
Which of the following questions is the priority for the nurse to ask the client?
- A. How do you manage your behavior?
- B. Do you have a criminal record?
- C. How do you get along with your peers at school?
- D. Do you have thoughts of harming yourself?
Correct Answer: D
Rationale: The correct answer is D. The nurse's priority is to assess for any immediate danger or harm to the client. Asking about thoughts of harming oneself is crucial in determining the client's safety. This question helps identify the client's risk of suicide and allows for timely intervention if needed. Choices A, B, and C focus on different aspects of the client's behavior and relationships, which are important but not as urgent as assessing for suicidal ideation. It is essential to address safety concerns first before exploring other areas.
Which of the following information should the nurse include in the teaching?
- A. Take mineral oil at bedtime
- B. Decrease insoluble fiber intake
- C. Drink 1,5 L of fluids each day.
- D. Increase exercise activity.
Correct Answer: D
Rationale: The correct answer is D: Increase exercise activity. This is important for promoting regular bowel movements and overall gastrointestinal health. Exercise helps stimulate the digestive system and aids in relieving constipation. Taking mineral oil (choice A) can interfere with nutrient absorption and is not recommended for long-term use. Decreasing insoluble fiber intake (choice B) can worsen constipation as fiber helps promote bowel regularity. Drinking 1.5 L of fluids each day (choice C) is important for hydration but alone may not be sufficient to improve bowel function. Increasing exercise activity (choice D) is the most effective way to promote healthy digestion and prevent constipation.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Instruct the client to avoid live vaccines, Instruct the client to use mild soaps for cleansing skin, Instruct the client to avoid foods high in purities, Instruct the client to apply tropical analgesics, Instruct the client to apply heat
- B. Systemic lupus erythematous, Osteoarithritis, Gout, Rheumatoid arthritis(RA)
- C. Uric acid level, ESH, Joint deformities, lymphadenopathy, ANA
Correct Answer:
Rationale: Gout presents with elevated uric acid levels.