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Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis?
- A. Rolling the client onto the side.
- B. Sliding the client to move up in bed.
- C. Lifting the client when moving the client up in bed.
- D. Having the client help lift off the bed using a trapeze.
Correct Answer: B
Rationale: Sliding the client can cause shear injuries to the skin, especially in hemiparalysis with reduced sensation. Rolling, lifting, or using a trapeze (if feasible) are safer techniques.
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A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
- A. Hyperalbuminemia.
- B. Thrombocytopenia.
- C. Hypokalemia.
- D. Hypercalcemia.
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours following surgery, the drainage unit is full. The nurse should do which of the following?
- A. Remove the drain from the incision.
- B. Notify the surgeon.
- C. Empty drainage.
- D. Record the amount in the unit as output on the client's chart.
Correct Answer: C
Rationale: A full portable wound suction unit (e.g., Jackson-Pratt) should be emptied to maintain suction and prevent complications. The drainage is then measured and recorded.
Which of the following areas is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer?
- A. The support available to assist the client at home.
- B. The distance the client lives from the hospital.
- C. The client's ability to do home blood pressure monitoring.
- D. The client's knowledge of the causes of lung cancer.
Correct Answer: A
Rationale: Home support is critical post-lobectomy to assist with recovery, medication adherence, and monitoring complications. Distance from the hospital, blood pressure monitoring, and knowledge of cancer causes are less immediate priorities.
What areas of education should the nurse provide the narrowness to a factory making the cause respiratory irritation to reduce the risk of laryngeal cancer? Select all that apply.
- A. Smoking cessation concurrent with counseling.
- B. HEPA filter use in the home.
- C. Limiting alcohol use.
- D. Brushing teeth after every meal.
- E. Raising the voice to be heard over the noise in the factory.
Correct Answer: A,C
Rationale: Smoking and excessive alcohol use are major risk factors for laryngeal cancer; cessation and moderation reduce risk. HEPA filters address general air quality but not specific carcinogens. Brushing teeth and raising the voice are unrelated to laryngeal cancer risk.
The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of:
- A. Atrophy
- B. Contraction
- C. Gangrene
- D. Rubor
Correct Answer: C
Rationale: A black great toe in a client with PVD likely indicates gangrene, resulting from tissue necrosis due to severe ischemia from arterial occlusion. Atrophy causes muscle wasting, contraction is not a relevant term, and rubor refers to reddish discoloration, not black.