Nokea
Which of the following suggestions should the nurse give to an adolescent football player with Osgood-Schlatter disease of the left knee?
- A. Apply ice on the knee after playing.
- B. Use crutches until healing has occurred.
- C. Stop playing until healing has occurred.
- D. Make an appointment with a physical therapist.
Correct Answer: A
Rationale: Applying ice after activity reduces inflammation and pain in Osgood-Schlatter disease.
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The nurse is assisting a primary health care provider with abdominal paracentesis. What position should the nurse assist the client into for this procedure?
- A. Prone
- B. Supine
- C. Semi-Fowler's on the back
- D. Low Fowler's on the right side
Correct Answer: C
Rationale: For abdominal paracentesis, the nurse should position the client in either a semi-Fowler's position or an upright position on the edge of the bed with the feet resting on a stool and the back well supported. This position allows the intestine to float posteriorly and helps prevent laceration during catheter insertion. None of the remaining options suggest the correct position.
A client with a history of heart failure is admitted with dyspnea. Which position should the nurse place the client in?
- A. Fowler's position
- B. Supine with legs elevated
- C. Prone position
- D. Trendelenburg position
Correct Answer: A
Rationale: Fowler's position (semi-upright) reduces preload and eases breathing in heart failure clients with dyspnea.
When infusing total parenteral nutrition (TPN), the nurse should assess the client for which of the following complications?
- A. Essential amino acid deficiency.
- B. Essential fatty acid deficiency.
- C. Hyperglycemia.
- D. Infection.
Correct Answer: C,D
Rationale: TPN can cause hyperglycemia due to high glucose content and infection due to catheter use, both requiring vigilant monitoring.
The nurse is caring for a client with a diagnosis of peptic ulcer disease. When monitoring the client for possible gastrointestinal perforation, the nurse identifies the importance of what assessment data?
- A. Slow, strong pulses
- B. Increase in bowel sounds
- C. Positive guaiac stool tests
- D. Sudden, severe abdominal pain
Correct Answer: D
Rationale: Sudden, severe abdominal pain is a sign of perforation. When perforation occurs, the pulse will more likely be weak and rapid. The nurse may be unable to hear bowel sounds at all. Positive guaiac stool results indicate the presence of bleeding but are not necessarily indicative of perforation.
The nurse is caring for a client with a history of burns covering 30% of the body. Which of the following interventions should be prioritized?
- A. Administer I.V. fluids.
- B. Apply antibiotic cream.
- C. Monitor for infection.
- D. Administer analgesics.
Correct Answer: A
Rationale: I.V. fluids are the priority to replace fluid loss and prevent hypovolemic shock in burn injuries.