The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
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Solution
Answer A is correct. Frequent rest periods help to relax tense muscles and preserve energy. Answers B, C, and D are incorrect because they are untrue statements.
The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture?
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Solution
Answer D is correct. A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea. Answers A, B, and C are incorrect because these cultures do not test for gonorrhea.
Which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy?
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Solution
Answer D is correct. After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not diets for this type of surgery.
The nursing is participating in discharge teaching for the postpartal client. The nurse is aware that an effective means of managing discomfort associated with an episiotomy after discharge is:
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Solution
Answer C is correct. A sitz bath will help with swelling and improve healing. Ice packs, in answer D, can be used immediately after delivery. Answers A and B are not used in this instance.
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
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Solution
Answer B is correct. The best way to evaluate pain levels is to ask the client to rate his pain on a scale. In answer A, the blood pressure, pulse, and temperature can alter for other reasons than pain. Answers C and D are not as effective in determining pain levels.
The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, HCO3 28. The nurse would assess the client to be in:
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Solution
Answer C is correct. The client is experiencing compensated metabolic acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be the inverse of the CO2 and bicarb levels. This means that if the pH is low, the CO2 and bicarb levels will be elevated. Answers A, B, and D are incorrect because they do not fall into the range of symptoms.
The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?
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Solution
Answer B is correct. The registered nurse is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor; therefore, answers A, C, and D are incorrect.
The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at:
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Solution
Answer C is correct. Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. This allows for accurate bleeding times to be drawn in the morning. Therefore, answers A, B, and D are incorrect.
A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?
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Solution
Answer C is correct. Covering both eyes prevents consensual movement of the affected eye. The nurse should not attempt to remove the object from the eye because this might cause trauma, as stated in answer A. Rinsing the eye, as stated in answer B, might be ordered by the doctor, but this is not the first step for the nurse. Answer D is not correct because often when one eye moves, the other also does.
To ensure safety while administering a nitroglycerine patch, the nurse should:
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Solution
Answer A is correct. To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the shin might abrade the area. Answer C is incorrect because washing with hot water will vasodilate Answer A is correct. To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the shin might abrade the area. Answer C is incorrect because washing with hot water will vasodilate