Extract:

Question 1 of 5

Which nursing action should the nurse implement to prevent wound dehiscence in the postoperative client?

A. Increase the client's intake of Vitamin C.B. Teach the client to splint the incision when coughing.C. Have the client do abdominal exercises.D. Perform passive range of motion exercises.

Correct Answer: B

Rationale: Splinting the incision (
B) reduces dehiscence risk. Vitamin C (
A), abdominal exercises (
C), and range of motion (
D) are less effective.

Question 2 of 5

A client with rheumatoid arthritis is prescribed infliximab 3 mg/kg IV. The most essential addition to the client's care plan is to:

A. hold the drug if the client is feeling better.B. take the medication with food or milk.C. use good handwashing technique.D. give the drug early in the morning

Correct Answer: C

Rationale: The drug should not be held based on how the client feels. Infliximab is prescribed based on specific treatment protocols, and stopping it could negatively impact disease management. Infliximab can be taken regardless of food intake, so it's not necessary to take it with food or milk. Infliximab is an immunosuppressive medication, which increases the risk of infections. Teaching the client and caregivers about the importance of hand hygiene is essential in preventing infections. There is no requirement for the drug to be given specifically in the morning. It can be given according to the prescribed schedule, typically at intervals based on disease management.

Question 3 of 5

The client diagnosed with pneumonia asks the nurse, "Why did my physician order chest physiotherapy (CPT) for me?" Which response by the nurse is most accurate? Chest physiotherapy will:

A. Improve the ciliary movement in the lungs.B. Increase your ability to take deep breaths.C. Loosen secretions in congested areas of the lungs.D. Increase the oxygen supply to your tissues.

Correct Answer: C

Rationale: CPT loosens secretions (
C) to improve ventilation. Ciliary movement (
A), deep breathing (
B), and oxygen supply (
D) are secondary.

Question 4 of 5

Which interventions should be included in discharge teaching for a client who has had a total hip replacement? (SELECT ALL THAT APPLY)

A. Explain the importance of increasing activity gradually.B. Have the client demonstrate use of assistive devices.C. Discuss use of abductor pillow between thighs when turning in bed.D. Tell the client to ambulate with open-toed house shoes.E. Instruct the client not to take medication prior to ambulating

Correct Answer: A,B,C

Rationale: Gradually increasing activity helps in recovery and prevents complications like blood clots. Having the client demonstrate the use of assistive devices ensures proper use and safety during ambulation. Using an abductor pillow helps maintain hip alignment and prevents dislocation while turning in bed. Open-toed house shoes are not recommended as they do not provide adequate support or protection. It is important for the client to manage pain appropriately, including taking medication before activities such as walking.

Question 5 of 5

The nurse is planning the care of a client diagnosed with emphysema. The client is not currently reporting increased dyspnea, but the nurse has noted the client is anxious. Which nursing intervention(s) should be implemented?

A. Administer their inhaler medications and increase the oxygen.B. Notify the physician and administer lorazepam.C. Dim the lights and encourage the client to take a nap.D. Sit with the client and provide comfort measures.

Correct Answer: D

Rationale: Comfort measures (
D) address anxiety non-pharmacologically. Inhalers/oxygen (
A), lorazepam (
B), or napping (
C) are less immediate.