Nokea
Which of the following evening snacks would the nurse encourage for the client with immobility due to the fractured hip?
- A. An orange
- B. Rice cakes
- C. Peanut butter and celery
- D. Potato chips
Correct Answer: C
Rationale: Peanut butter and celery provide protein and healthy fats, supporting tissue repair and nutrition during immobility. Oranges offer vitamin C but less protein, while rice cakes and potato chips lack substantial nutritional value.
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Which area of health teaching is essential to include in the discharge instructions for a client who has undergone a total hip replacement?
- A. Modifying ways of donning clothing
- B. Using special equipment for bathing
- C. Taking vigorous daily walks
- D. Receiving a daily stool softener
Correct Answer: A
Rationale: Modifying clothing application (e.g., avoiding bending or crossing legs) prevents hip dislocation, making it essential for discharge teaching. Vigorous walks are contraindicated, and the other options are less critical.
The nurse is assessing the leg of a client in Russell's traction. Which area is it essential to assess?
- A. Pedal area
- B. Femoral area
- C. Popliteal area
- D. Inner aspect of the thigh
Correct Answer: A
Rationale: Assessing the pedal area checks for circulation, sensation, and movement, critical in traction to detect neurovascular compromise.
The nurse is caring for the client 2 days post-right THR in which the traditional posterior approach was used. Which interventions should the nurse implement?
- A. Checks that an elevated toilet seat is in place and assists the client to the bathroom using a walker
- B. Removes the wedge pillow at the client's request and places pillows to maintain right leg adduction
- C. Reinfuses the 400-mL wound autotransfusion drainage system returns that collected in the past 24 hours
- D. Assists the client to get out of bed on the left side so the client can stand to place and use the urinal
Correct Answer: A
Rationale: A. The client should be able to ambulate with the use of a walker. An elevated toilet seat is used to prevent hip flexion of greater than 90 degrees when the client sits.
Which statement by the client prescribed calcitonin, a thyroid hormone, indicates to the nurse the teaching has been effective?
- A. I should administer the mediation in a different nostril each day.'
- B. I need to drink a lot of water when I take my medicine.'
- C. I have to dilute the medication with vitamin D before I take it.'
- D. This medication will help the calcium leave my bones.'
Correct Answer: A
Rationale: Alternating nostrils for nasal calcitonin prevents irritation, indicating effective teaching. Water intake, vitamin D dilution, and calcium loss are incorrect.
The nurse is caring for the client after a right TKR. To prevent circulatory complications, the nurse should ensure that the client is performing which action?
- A. Flexing both feet and exercising uninvolved joints every hour while awake
- B. Using the continuous passive motion device (CPM) every 2 hours for 30 minutes
- C. Being assisted up to a chair as soon as the effects of anesthesia have worn off
- D. Using the trapeze to lift off the bed and then rotating each leg intermittently
Correct Answer: A
Rationale: A. Dorsiflexion of the foot promotes muscle contraction, which compresses veins. This reduces venous stasis and risk of thrombus formation. It should be performed every hour while awake.