Nokea
Which question best helps the nurse determine whether the client is experiencing an adverse effect from taking nonsteroidal anti-inflammatory drugs (NSAIDs)?
- A. Do you have any stomach pain or black stools?
- B. Are you experiencing any joint swelling?
- C. Have you noticed any changes in your vision?
- D. Are you feeling more tired than usual?
Correct Answer: A
Rationale: Stomach pain or black stools indicate gastrointestinal bleeding, a serious NSAID side effect.
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Which assessment finding most likely indicates that a client has osteoporosis?
- A. Swollen joints
- B. Discomfort when sitting
- C. Spinal deformity
- D. Diminished energy level
Correct Answer: C
Rationale: Spinal deformity, like kyphosis, is a common sign of osteoporosis.
What equipment is best for preventing external rotation of the operative leg when caring for a client with a total hip replacement?
- A. A footboard
- B. A trochanter roll
- C. A turning sheet
- D. A foam mattress
Correct Answer: B
Rationale: A trochanter roll placed along the hip prevents external rotation of the operative leg, maintaining proper alignment post-hip replacement. The other options do not specifically address rotation.
The client who has sustained a left-sided cerebrovascular accident (stroke) has residual right-sided paralysis. The nurse identifies a concept of impaired functional ability. Which should be included in the care map? Select all that apply.
- A. Refer to the occupational therapist.
- B. Assess the client for neglect of the right side.
- C. Place the client in a room where the door is on the left side.
- D. Teach the client to call for assistance prior to getting out of bed.
- E. Encourage the client to participate in physical therapy daily.
Correct Answer: A,B,D,E
Rationale: OT referral, neglect assessment, fall prevention, and PT promote functional ability post-stroke. Room orientation is less critical.
Which evidence is the best indication that the client who had a knee arthroplasty is recovering according to expected outcomes and no longer needs the continuous passive motion (CPM) machine?
- A. The client has minimal pain when ambulating.
- B. The client can flex the operative knee 90 degrees.
- C. The client can tolerate full weight bearing.
- D. The edges of the client's surgical wound are approximated.
Correct Answer: B
Rationale: 90-degree knee flexion indicates restored joint function, a key recovery milestone.
The client with a long arm cast is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect the client is experiencing?
- A. Fat embolism.
- B. Compartment syndrome.
- C. Pressure ulcer under the cast.
- D. Surgical incision infection.
Correct Answer: B
Rationale: Severe pain and numbness in a casted arm suggest compartment syndrome, a medical emergency. Fat embolism, pressure ulcers, and infections present differently.