A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse
... [Show More] ensure that the client has available at home prior to discharge?
Continuous passive motion device
Elevated toilet seat
Trapeze bar
Compression garment Ans: Elevated toilet seat
A client who is postoperative following a total hip arthroplasty is at risk for dislocation of the hip prosthesis. Limitations on hip flexion and adduction decrease the risk. The client should avoid flexing the hip greater than 90° and should avoid using toilet seats that are low to the ground. An elevated toilet seat should be in place in the client's home prior to the client's discharge.
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (select all that apply)
Elevated WBC count
Elevated amylase level
Rebound tenderness
Ascites
Anorexia Ans: Elevated WBC count
A client who has acute appendicitis will show a moderate elevation of the WBC count from 10,000 to 18,000/mm3. If the WBC count is greater than 20,000/mm3, it can indicate a perforated appendix.
Rebound tenderness
A client who has appendicitis develops localized pain over the right lower quadrant of the abdomen. When the area is palpated, pain occurs during release of pressure on the client's abdomen.
Anorexia
A client who has acute appendicitis experiences nausea, vomiting, and reduced appetite.
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
"I am aware that my diabetes is caused by an autoimmune disorder."
"I know that my diabetes developed slowly over several years."
"If I lose weight, I may be able to stop taking insulin."
"I have developed a resistance to insulin." Ans: "I am aware that my diabetes is caused by an autoimmune disorder."
Type 1 diabetes mellitus is an autoimmune disorder that destroys pancreatic beta cells. This autoimmune reaction is often triggered by a viral infection.
A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy?
WBC count 8,000/mm3
RBC count 6 million/mm3
BUN 24 mg/dL
Potassium 3.5 mEq/L Ans: BUN 24 mg/dL
A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating renal impairment. An adverse effect of cyclosporine is nephrotoxicity. The nurse should monitor the client for increases in BUN and creatinine and report any elevation to the provider. A rise in BUN could indicate transplant rejection.
A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take?
Give detailed directions when addressing the client.
Provide finger food at mealtime.
Use written signs to redirect the client.
Seat the client at a large table for meals. Ans: Provide finger food at mealtime.
The nurse should provide the client who has dementia with fingers foods. Clients who have dementia can have difficulty sitting still and tend to wander, which makes weight loss and malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal.
A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?
Feel for exhaled air emerging from the endotracheal tube.
Assess for bilateral breath sounds.
Observe for symmetric chest movement.
Check for end-tidal carbon dioxide levels. Ans: Check for end-tidal carbon dioxide levels.
According to evidence-based practice, the most reliable method for verifying ET tube placement is checking for end-tidal carbon dioxide levels by using capnometry. A chest x-ray is another reliable method for verifying placement. [Show Less]