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NEW QUESTION 23
A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?

• A. Check neurological and circulatory status of the affected leg hourly.
• B. Encourage her to cross and uncross her legs.
• C. Place a trochanter roll along the upper thigh of the affected leg.
• D. Encourage exercises in the unaffected extremities.

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A) Exercising the unaffected extremities will prevent contractures and emboli. (B) Crossing and uncrossing the affected leg after surgery can dislocate the joint. (C) Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. (D) A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.

NEW QUESTION 24
The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse's action should be to:

• A. Remove the postoperative dressing to check for bleeding
• B. Increase O2 from 2-3 L/min
• C. Obtain arterial blood gases
• D. Encourage coughing and deep breathing each hour

Answer: D

Explanation:
Explanation
(A) Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. (B) Arterial blood gases are not indicated because there is no other information indicating impendingdanger. (C) Increasing O2 rate is not indicated without additional information. (D) Removing the dressing is not indicated without additional information.

NEW QUESTION 25
A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?

• A. Monitor intake and output.
• B. Weigh the child twice daily on the same scale.
• C. Observe for edema.
• D. Check urine specific gravity of each voiding.

Answer: B

Explanation:
Explanation
(A) Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. (B) Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. (C) Urine specific gravity does not necessarily indicatefluid volume excess. (D) Edema may not be apparent, yet the client may have fluid volume excess.

NEW QUESTION 26
The physician decides to prescribe both a short-acting insulin and an intermediate-acting insulin for a newly diagnosed 8-year-old diabetic client. An example of a short-acting insulin is:

• A. Protamine zinc insulin
• B. Lente Beef
• C. Humulin NPH
• D. Novolin Regular

Answer: D

Explanation:
Explanation
(A) Novolin is a short-acting insulin. (B, C) NPH and Lente are intermediate-acting insulins. (D) Protamine zinc insulin is a long-acting insulin preparation.

NEW QUESTION 27
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