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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. How should a healthcare professional respond to a patient with hypokalemia?
- A. Administer potassium supplements and monitor ECG
- B. Restrict fluid intake and provide a high-sodium diet
- C. Monitor sodium levels and provide insulin therapy
- D. Provide calcium supplements and monitor for hyperkalemia
Correct answer: A
Rationale: Hypokalemia is managed by administering potassium supplements to correct the low potassium levels in the body. Monitoring the ECG is essential because low potassium levels can lead to cardiac arrhythmias. Choice B is incorrect as restricting fluid intake and providing a high-sodium diet are not appropriate for managing hypokalemia. Choice C is incorrect because hypokalemia involves low potassium levels, not sodium levels, and insulin therapy does not directly address this issue. Choice D is incorrect as calcium supplements are not indicated for hypokalemia, and monitoring for hyperkalemia is not relevant in this case.
3. A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?
- A. Encourage deep breathing exercises
- B. Maintain the client in a supine position
- C. Apply a sequential compression device
- D. Massage the client's legs
Correct answer: C
Rationale: The correct answer is C: Apply a sequential compression device. Applying a sequential compression device promotes venous return by assisting with blood circulation in the lower extremities, reducing the risk of blood clots. Encouraging deep breathing exercises can help with lung expansion but does not directly promote venous return. Maintaining the client in a supine position may not be ideal for promoting venous return if the client is unable to move. Massaging the client's legs may be contraindicated postoperatively due to the risk of dislodging a clot or causing trauma to the surgical site.
4. When providing discharge instructions for a client with home oxygen, what safety measure should the nurse emphasize?
- A. Prohibit smoking near oxygen equipment
- B. Ensure the client uses non-flammable bedding
- C. Ensure oxygen tanks are stored upright
- D. Keep the oxygen equipment at least 6 feet away from heat sources
Correct answer: D
Rationale: The correct answer is to keep the oxygen equipment at least 6 feet away from heat sources. Placing oxygen equipment near heat sources can lead to fire hazards due to the oxygen's combustible nature. Option A is the correct safety measure as smoking near oxygen equipment can cause fires due to oxygen's flammable properties. Option B regarding the use of non-flammable bedding is not directly related to oxygen safety. Option C is important for proper oxygen tank functioning but is not as critical as keeping the equipment away from heat sources to prevent fires.
5. A client has developed phlebitis at the IV site. What is the next step the nurse should take?
- A. Administer an anti-inflammatory medication
- B. Discontinue the IV and notify the provider
- C. Apply a cold compress over the IV site
- D. Increase the IV flow rate to prevent dehydration
Correct answer: B
Rationale: When a client develops phlebitis at the IV site, the nurse's immediate action should be to discontinue the IV and notify the healthcare provider. Phlebitis is inflammation of the vein, and leaving the IV in place can lead to complications such as infection or thrombosis. Administering an anti-inflammatory medication (choice A) may not address the root cause and delay the necessary intervention. Applying a cold compress (choice C) may provide temporary relief but does not address the need to remove the source of inflammation. Increasing the IV flow rate (choice D) is contraindicated as it can exacerbate the phlebitis by causing more irritation to the vein.
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