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Which of the following statements would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?
- A. Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks.
- B. Activity level is determined by the client's tolerance; she can be as active as she wishes.
- C. Activity level will be restricted for several months, so she should plan on being sedentary.
- D. Activity level can return to normal and may include regular aerobic exercises.
Correct Answer: A
Rationale: Gradual resumption of activity over 5 to 6 weeks allows the retina to heal properly while minimizing the risk of re-detachment or complications.
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The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution:
- A. Provide essential fatty acids.
- B. Provides extra carbohydrates.
- C. Promotes effective metabolism of glucose.
- D. Maintains a normal body weight.
Correct Answer: A
Rationale: Fat emulsion solutions in TPN provide essential fatty acids to prevent deficiency. They do not primarily provide carbohydrates, promote glucose metabolism, or maintain body weight. CN: Pharmacological and parenteral therapies; CL: Apply
After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would be most appropriate to include in a low-fat diet?
- A. Cheese omelet.
- B. Peanut butter.
- C. Ham salad sandwich.
- D. Roast beef.
Correct Answer: D
Rationale: A low-fat diet minimizes gallbladder workload. Roast beef (D) is leaner compared to a cheese omelet (A), peanut butter (B), or ham salad sandwich (C), which are high in fat. Thus, roast beef is the most appropriate choice.
A nurse is caring for a client with a central venous catheter (CVC) in place. Which action by the nurse is most effective in preventing central line-associated bloodstream infections (CLABSI)?
- A. Performing hand hygiene before and after any manipulation of the CVC.
- B. Monitoring the client's temperature every 4 hours.
- C. Administering prophylactic antibiotics.
- D. Ensuring the client maintains strict bed rest to prevent catheter movement.
Correct Answer: A
Rationale: Hand hygiene is the most effective measure to prevent CLABSI by reducing microbial contamination.
Which of the following rehabilitative measures should the nurse teach the client who has undergone chest surgery to prevent shoulder ankylosis?
- A. Turn from side to side.
- B. Raise and lower the head.
- C. Raise the arm on the affected side over the head.
- D. Flex and extend the elbow on the affected side.
Correct Answer: C
Rationale: Raising the arm overhead prevents shoulder ankylosis (stiffness) by maintaining range of motion post-chest surgery. Other movements are less specific to shoulder mobility.
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (B) and urine output (C) are general but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis severity.