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1. A client who has a new prosthesis for an above-the-knee amputation of the right leg needs teaching on its use. Which of the following instructions should the nurse include?
- A. Wear the prosthesis for 2 hours at a time
- B. Remove the prosthesis every other day
- C. Apply the prosthesis immediately upon waking each day
- D. Elevate the stump for 24 hours after applying the prosthesis
Correct answer: C
Rationale: The correct instruction is to apply the prosthesis immediately upon waking each day. This helps the client adjust to and maintain mobility. Choice A is incorrect because wearing the prosthesis for only 2 hours at a time may not be sufficient for proper adjustment. Choice B is incorrect as removing the prosthesis every other day is not a standard practice and may hinder the client's mobility. Choice D is incorrect because elevating the stump for 24 hours after applying the prosthesis is unnecessary and not a recommended practice.
2. A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?
- A. In the afternoon
- B. As soon as the client awakens in the morning
- C. Before bedtime
- D. Immediately after lunch
Correct answer: B
Rationale: The correct answer is B: 'As soon as the client awakens in the morning.' Sputum specimens should be collected early in the morning to obtain a concentrated sample. This timing ensures that the specimen is less diluted, providing a more accurate analysis. Choices A, C, and D are incorrect as they do not align with the optimal timing for collecting a sputum specimen, which is in the morning.
3. Which instruction should be emphasized for a client with diabetes being discharged?
- A. Check blood sugar once daily
- B. Take insulin before meals as prescribed
- C. Monitor glucose levels weekly
- D. Eat carbohydrate-rich meals to maintain glucose levels
Correct answer: B
Rationale: The correct answer is to 'Take insulin before meals as prescribed' because it is crucial for managing blood glucose levels effectively in clients with diabetes. Insulin helps the body utilize glucose from the food consumed, preventing high blood sugar levels. Checking blood sugar once daily (Choice A) may not be sufficient for proper management, as blood sugar levels can fluctuate throughout the day. Monitoring glucose levels weekly (Choice C) is too infrequent and may lead to missed opportunities for timely intervention. Eating carbohydrate-rich meals to maintain glucose levels (Choice D) is not appropriate advice, as it can cause rapid spikes in blood sugar levels, especially without the proper insulin dosage.
4. A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?
- A. Bright red bleeding
- B. Burning with urination
- C. Headache
- D. Heavy lochia flow
Correct answer: B
Rationale: The correct answer is B: 'Burning with urination.' Burning with urination can indicate a urinary tract infection postpartum, which requires immediate attention to prevent complications. Bright red bleeding and heavy lochia flow are expected findings in the early postpartum period as the uterus continues to contract and expel lochia. A headache alone is not uncommon postpartum and is often attributed to hormonal changes, dehydration, or fatigue, and can be managed with adequate rest, hydration, and pain relief. Therefore, the priority here is to address the potential infection indicated by burning with urination.
5. Which of the following is the best strategy for managing dehydration in a client?
- A. Encourage the client to drink more water
- B. Monitor fluid and electrolyte levels frequently
- C. Administer oral rehydration solutions
- D. Increase the IV fluid rate
Correct answer: B
Rationale: The best strategy for managing dehydration in a client is to monitor fluid and electrolyte levels frequently. This allows healthcare providers to assess the client's hydration status accurately and make informed decisions regarding treatment. Encouraging the client to drink more water (Choice A) may not be sufficient if the dehydration is severe and requires specific interventions. Administering oral rehydration solutions (Choice C) can be beneficial but should be guided by monitoring the client's condition. Increasing the IV fluid rate (Choice D) may be necessary in certain cases, but it is not always the initial or best approach, as monitoring is crucial to avoid fluid and electrolyte imbalances.
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