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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 client has hyperthermia. Which of the following actions should the nurse take?
- A. Submerge the client's feet in ice water.
- B. Cover the client with a thermal blanket.
- C. Administer oral acetaminophen.
- D. Initiate seizure precautions.
Correct answer: C
Rationale: Administering oral acetaminophen is the appropriate intervention for a client with hyperthermia. Acetaminophen helps to reduce fever by lowering the body's temperature. Submerging the client's feet in ice water can lead to shock and is not recommended. Using a thermal blanket may worsen the condition by trapping heat. Initiating seizure precautions is not directly related to managing hyperthermia.
3. What are the complications of untreated Type 1 diabetes?
- A. Diabetic ketoacidosis and retinopathy
- B. Hypoglycemia and neuropathy
- C. Hypotension and kidney failure
- D. Infection and fluid overload
Correct answer: A
Rationale: Diabetic ketoacidosis and retinopathy are indeed common complications of untreated Type 1 diabetes. Diabetic ketoacidosis occurs when the body starts breaking down fat for fuel, leading to a dangerous buildup of ketones in the blood. Retinopathy refers to damage to the blood vessels of the retina due to high blood sugar levels over time. The other choices, hypoglycemia and neuropathy (choice B), hypotension and kidney failure (choice C), and infection and fluid overload (choice D) are not typically the primary complications associated with untreated Type 1 diabetes.
4. Which of the following interventions is the best to improve the healing of a pressure ulcer for a client with a low serum albumin level?
- A. Provide high-calorie, high-protein supplements
- B. Consult a dietitian to create a high-protein diet plan
- C. Administer nutritional supplements
- D. Increase IV fluids to prevent dehydration
Correct answer: B
Rationale: Consulting a dietitian to create a high-protein diet plan is the best intervention for a client with a low serum albumin level to promote healing. This approach ensures that the client receives the specific nutrients needed for wound healing. Providing high-calorie, high-protein supplements (choice A) may not address the specific nutritional deficiencies of the client. Administering nutritional supplements (choice C) is vague and may not target the necessary nutrients for wound healing. Increasing IV fluids (choice D) is important for hydration but does not directly address the nutritional needs of the client to improve ulcer healing.
5. A client with chronic kidney disease needs dietary restrictions. What restriction is necessary?
- A. Increase protein intake
- B. Limit potassium-rich foods
- C. Increase fluid intake to prevent dehydration
- D. Increase phosphorus intake
Correct answer: B
Rationale: The correct answer is to limit potassium-rich foods for clients with chronic kidney disease. Excessive potassium can be harmful to individuals with compromised kidney function, leading to complications. This restriction helps in managing the condition and preventing further health issues. Choice A is incorrect because increasing protein intake can put additional stress on the kidneys. Choice C is incorrect as excessive fluid intake can burden the kidneys. Choice D is incorrect as increasing phosphorus intake can be harmful for individuals with kidney disease.
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