Nokea
Which of the following interventions would be least appropriate for a client who is in a double hip spica cast?
- A. Encouraging the intake of cranberry juice.
- B. Advising the client to eat large amounts of cheese.
- C. Establishing regular times for elimination.
- D. Having the client dangle at the bedside.
Correct Answer: D
Rationale: Dangling at the bedside is inappropriate, as it risks cast damage and improper positioning.
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The nurse's assignment consists of the following four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report?
- A. The client with cirrhosis who became confused and disoriented during the night.
- B. The client with acute pancreatitis who is requesting pain medication.
- C. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted.
- D. The client with hepatitis B who has questions about his discharge instructions.
Correct Answer: A,B,C,D
Rationale: Confusion in cirrhosis (A) indicates possible hepatic encephalopathy, a priority. Pain in pancreatitis (B) requires prompt relief. Postoperative T-tube monitoring (C) is next. Discharge teaching (D) is lowest priority.
The nurse should assess the client with bladder cancer for which of the following?
- A. Suprapubic pain.
- B. Dysuria.
- C. Painless hematuria.
- D. Urine retention.
Correct Answer: C
Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often presenting as the initial sign due to tumor growth causing bleeding without associated pain.
Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon?
- A. Showering.
- B. Lifting anything heavier than 10 lb.
- C. A program of gradually progressive walking.
- D. Light housework.
Correct Answer: B
Rationale: Lifting heavy objects (>10 lb) risks sternal dehiscence post-mitral valve replacement, so it is restricted until surgeon approval.
A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to:
- A. Provide access for wound irrigation.
- B. Promote drainage of wound exudate.
- C. Minimize development of scar tissue.
- D. Decrease postoperative discomfort.
Correct Answer: B
Rationale: The drain in the incisional site of a perforated appendix promotes drainage of wound exudate to prevent infection and abscess formation. It is not for irrigation, scar prevention, or direct pain relief. CN: Physiological adaptation; CL: Apply
A client with a hip fracture is using a walker. Which observation indicates incorrect use of the walker?
- A. The client leans forward over the walker.
- B. The client advances the walker before stepping.
- C. The client uses the walker on both sides.
- D. The client keeps elbows slightly bent.
Correct Answer: A
Rationale: Leaning forward over the walker compromises balance and increases fall risk.