Question

1. A nurse is developing a plan of care for a client who is returning from the PACU following a left below-the-knee amputation. Which of the following interventions should the nurse include in the plan?

1. Place the client's residual limb in a dependent position when possible.
2. Keep the client in a supine position for the first 48 hr.
3. Provide the client with a firm mattress.
4. Wrap the client's residual limb with elastic bandage in a distal to proximal direction.

2. A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia?

1. Positive Chvostek's sign
2. Muscle weakness
3. Oliguria
4. Hypertension

3. a nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take?

1. Leave unused equipment in the client's room until discharge.
2. Move the client's soiled linens to a designated container outside the room.
3. Attach a dosimeter badge to the client's gown.
4. Place long handled forceps at the client's bedside.

4. A nurse is assessing a client following extubating from a ventilator. For which of the following findings should the nurse intervene immediately?

A.         SaO2 92%

B.         Stridor

C.         Sore throat

D.         Rhonchi

5.         A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

A.         Normotensive blood pressure

B.         Absence of a bruit

C.         Dilated appearance of the graft

D.         Palpable thrill

49.       A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client

reports sharp lower abdominal pain. Which of the following actions should the nurse take first?

A.         Check the client's urine output.

B.         Administer PRN pain medication

C.         Increase the client's fluid intake.

D.         Reposition the client in bed

50.       A nurse is caring for a client who is the caregiver for a relative who has a chronic disease. Which of the following statements indicates the client is adapting to the role change?

A.         "I need to get my blood pressure medicine refilled."

B.         had to reschedule my doctor's appointment last week."

C.         "I've lost 15 pounds in the past 2 months."

D.         "I have lunch with my friends once a week."

Answer 1

1) * PLACE THE CLIENTS RESIDUAL LIMB IN A DEPENDENT POSITION WHEN POSSIBLE- THIS HELPS TO PREVENTION OF OEDEMA AFTER AMPUTATION. * PROVIDE THE CLIENTS WITH FIRM MATTRESS- FIRM MATTRESS IS ESSENTIAL TO PREVENT MUSCLE CONTRACTURES. * WRAP THE CLIENTS RESIDUAL LIMB WITH ELASTIC BANDAGE IN A DISTAL TO PROXIMAL DIRECTIONS. - TO PREVENT INFECTION AND OEDEMA AFTER AMPUTATION. THE OTHER OPTION- KEEP THE CLIENT IN A SUPINE POSITION FOR THE 48 HOURS- THE POSITION GIVEN AFTER BELOW KNEE AMPUTATION IS PRONE POSITION IS HELPS TO STRETCHES THE MUSCLE AT FRONT OF THE HIPS.