A client with gallstones in the gall bladder is scheduled for lithotripsy. For the procedure, the client will be placed:
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Solution
Answer A is correct because it is the position used for lithotripsy for the client with gallstones in the gall bladder. Answer B is incorrect because it is the position used for lithotripsy for the client with gallstones in the common bile duct. Answers C and D are incorrect because side-lying and recumbent positions do not allow the maximum effect of therapy.
A suitable diet for a client with cirrhosis and abdominal ascites is one that is:
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Solution
Answer C is correct. The client with ascites requires additional protein and calories unless the client’s condition deteriorates because of renal involvement. In that case, protein intake is restricted. Answer A is incorrect because the client needs a low-sodium diet. Answer B is incorrect because the client does not need to decrease his intake of potassium. Answer D is incorrect because the client needs adequate amounts of calcium-rich foods that are also excellent sources of protein.
A client has been receiving Rheumatrex (methotrexate) for severe rheumatoid arthritis. The nurse should tell the client to avoid taking:
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Solution
Answer B is correct. The client taking methotrexate should avoid multivitamins because they contain folic acid. Folic acid is the antidote for methotrexate. Answers A and D are incorrect because aspirin and acetaminophen are given to relieve pain and inflammation associated with rheumatoid arthritis. Answer C is incorrect because omega 3 and omega 6 fish oils have proven beneficial for the client with rheumatoid arthritis.
A client is diagnosed with stage III Hodgkin’s lymphoma. The nurse recognizes that the client has involvement:
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Solution
Answer C is correct. Stage III Hodgkin’s lymphoma is characterized by lymph node involvement on both sides of the diaphragm. Answer A refers to stage I Hodgkin’s lymphoma; therefore, it is incorrect. Answer B refers to stage II Hodgkin’s lymphoma; therefore, it is incorrect. Answer D refers to stage IV Hodgkin’s lymphoma; therefore, it is incorrect.
Acticoat (silver nitrate) dressings are applied to the arms and chest of a client with full-thickness burns. The nurse should:
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Solution
Answer B is correct. The dressings should be moistened with sterile water. Answer A is incorrect because Acticoat dressings remain in place up to 5 days. Answer C is incorrect because the dressings should be changed every 4 or 5 days. Answer D is incorrect because normal saline should not be used to moisten the dressing.
A nursing assistant is referred to the employee health office with symptoms of latex allergy. The first symptom usually noticed by those with latex allergy is:
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Solution
Answer D is correct. The first sign of a latex allergy is usually contact dermatitis, which includes swelling and itching of the hands. Answers A, B, and C can also occur but are not the first signs of latex allergy; therefore, they are incorrect.
The nurse is caring for a client following a right nephrolithotomy. Post-operatively, the client should be positioned:
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Solution
Answer C is correct. Following a nephrolithotomy, the client should be positioned on the unoperative side. Answers A, B, and D are incorrect positions for the client following a nephrolithotomy.
An elderly client asks the nurse how often he will need to receive immunizations against pneumonia. The nurse should tell the client that she will need an immunization against pneumonia:
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Solution
Answer C is correct. Immunization against pneumonia is recommended every 5 years for persons over age 65, as well as for those with a chronic illness. Answers A and B are incorrect because the client still has immunity from the vaccine. Answer D is incorrect because the client should have received the booster immunization much sooner.
A client is admitted with Clostridium difficile. The nurse would expect the client to have:
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Solution
Answer A is correct. Pseudomembranous colitis results from infection with Clostridium difficile. Symptoms of pseudomembranous colitis include diarrhea containing blood, mucus, and white blood cells. Answers B, C, and D are incorrect because they are not symptoms of infection with Clostridium difficile.
The chart of a client hospitalized with a fractured femur reveals that the client is colonized with MRSA. The nurse knows that the client:
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Solution
Answer A is correct. The client who is colonized with MRSA will have no symptoms associated with infection. Answer B is incorrect because the client is more likely to develop an infection with MRSA following invasive procedures. Answer C is incorrect because the client should not be placed in the room with others. Answer D is incorrect because the client can colonize others, including healthcare workers, with MRSA.