Question

A nurse is reinforcing teaching with a client who is 24hr postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

Answer 1

Correct Answers:

Sit in a straight-backed chair.

Rationale :

🔷 After a total hip arthroplasty, the client should use a straight-backed, firm chair to help maintain proper hip alignment and avoid excessive flexion.

🔷 The client should generally avoid bending the hip beyond 90 degrees, crossing the legs, or adducting the operative hip because these movements can increase the risk of prosthetic dislocation.

🔷 A low, soft chair can cause excessive hip flexion when the client sits down or stands up.

🔷 Proper sitting position also supports safer transfers and reduces unnecessary stress on the newly replaced joint.

🔷 Teaching the client to use a straight-backed chair therefore promotes joint stability and prevention of postoperative hip dislocation.

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Answer 2

Correct Answers:

Ensure the signed consent is in the medical record.

Rationale :

🟣 An esophagogastroduodenoscopy (EGD) is an invasive procedure that requires informed consent before sedation and endoscope insertion.

🟣 The nurse should verify that the signed consent form is present in the medical record before the procedure begins.

🟣 The provider performing the procedure is responsible for explaining the risks, benefits, and alternatives, while the nurse verifies completion of the consent process.

🟣 The client is also typically maintained NPO for several hours before the procedure to decrease aspiration risk.

🟣 Confirming informed consent is therefore an essential preprocedure safety responsibility.

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Answer 3

Correct Answers:

"I will apply the stockings by starting at my feet and working up."

Rationale :

🟠 Compression stockings should be applied smoothly from the feet upward to promote venous return and prevent bunching or constriction.

🟠 The stockings should ideally be applied before the client gets out of bed, when dependent edema is minimal.

🟠 Wrinkles or folds should be smoothed because they can create localized pressure and impair circulation.

🟠 Proper use helps reduce venous stasis, lower-extremity edema, and risk of venous thromboembolism.

🟠 This statement demonstrates correct understanding of safe compression-stocking application.

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Answer 4

Correct Answers:

1000

Rationale :

🟢 Formula

✔️1 lb fat = 3,500 calories

✔️2 lb/week = 7,000 calories/week

✔️7,000 calories ÷ 7 days

➡️1,000 calories/day

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Answer 5

Correct Answers:

Instruct the client to breathe deeply and cough 1 time each hour.
Place the client in an upright sitting position.
Promote daily fluid intake of 2,500 mL.

Rationale :

Instruct the client to breathe deeply and cough 1 time each hour

🔵 Deep breathing and coughing help mobilize respiratory secretions and improve alveolar ventilation in a client with pneumonia.

🔵 Coughing promotes clearance of mucus that can otherwise obstruct airways and worsen gas exchange.

🔵 Regular pulmonary hygiene also helps decrease the risk of atelectasis and retained secretions.

🔵 The client should be encouraged to splint the chest if coughing causes discomfort and to rest between coughing exercises as needed.

🔵 Hourly deep breathing and coughing while awake therefore support airway clearance and lung expansion.

Place the client in an upright sitting position

🔵 An upright position promotes maximum lung expansion by allowing the diaphragm to descend more effectively.

🔵 It can improve ventilation and reduce the work of breathing in clients with pneumonia.

🔵 Upright positioning also facilitates coughing and drainage of respiratory secretions.

🔵 Clients with dyspnea often tolerate high-Fowler's or upright sitting better than lying flat.

🔵 This position therefore supports oxygenation and respiratory comfort.

Promote daily fluid intake of 2,500 mL

🔵 Adequate fluid intake helps thin respiratory secretions, making them easier to expectorate.

🔵 A daily intake around 2,500 mL, when not contraindicated by heart or renal disease, can support hydration during respiratory infection.

🔵 Hydration also replaces fluid losses associated with fever and increased respiratory rate.

🔵 Thinner secretions improve effectiveness of coughing and airway clearance.

🔵 Encouraging fluids therefore supports both hydration and pulmonary secretion management.

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Answer 6

Correct Answers:

"Weigh yourself every morning before breakfast."

Rationale :

🟡 Daily weight is one of the most sensitive ways to monitor fluid retention in clients with heart failure.

🟡 The client should weigh at the same time each morning, ideally after voiding and before eating breakfast.

🟡 Using the same scale and similar clothing improves consistency of measurements.

🟡 Rapid weight gain can indicate worsening fluid overload before obvious edema or severe shortness of breath develops.

🟡 Daily weights therefore allow earlier recognition and treatment of worsening heart failure.

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Answer 7

Correct Answers:

Family history

Rationale :

🟤 A family history of type 2 diabetes mellitus is a non-modifiable risk factor because genetic predisposition cannot be changed.

🟤 Having a first-degree relative with type 2 diabetes increases the likelihood of developing the disease.

🟤 Genetic susceptibility can interact with environmental factors such as diet, body weight, and physical inactivity.

🟤 Identifying family history helps the nurse determine whether the client needs earlier or more frequent diabetes screening and prevention counseling.

🟤 Family history is therefore the non-modifiable risk factor among the listed choices.

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Answer 8

Correct Answers:

"Sitting quietly near the bedside can provide comfort and support."

Rationale :

⚫ Increased sleeping and decreased responsiveness are common as a person approaches the end of life.

⚫ Family members can provide meaningful comfort simply by sitting quietly, holding the client's hand, or speaking softly.

⚫ Hearing may remain intact even when the dying client appears minimally responsive.

⚫ The nurse should normalize expected physiologic changes while supporting the partner's emotional needs.

⚫ Encouraging quiet presence respects the client's energy level while promoting comfort, dignity, and connection.

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Answer 9

Correct Answers:

The medication prevents the bladder muscles from involuntarily contracting.

Rationale :

🟥 Oxybutynin is an anticholinergic medication that relaxes the detrusor muscle of the bladder.

🟥 By reducing involuntary bladder contractions, it decreases urgency, frequency, and urge incontinence.

🟥 The medication works by blocking muscarinic acetylcholine receptors in bladder smooth muscle.

🟥 Common adverse effects can include dry mouth, constipation, blurred vision, and urinary retention because of its anticholinergic action.

🟥 The client's reduced urinary frequency therefore reflects decreased involuntary detrusor activity.

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Answer 10

Correct Answers:

Scopolamine

Rationale :

🟪 Scopolamine is an anticholinergic medication that decreases production of salivary and respiratory secretions.

🟪 In palliative and end-of-life care, it can help reduce noisy upper-airway secretions sometimes called the death rattle.

🟪 The medication works by blocking muscarinic receptors and reducing glandular secretion production.

🟪 Treatment is intended primarily to improve comfort for the client and reduce distress for family members observing the noisy breathing.

🟪 Scopolamine is therefore an appropriate medication for managing excessive terminal oral and respiratory secretions.

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QLexNursing

1 :
A nurse is reinforcing teaching with a client who is 24hr postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

2 :
A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take in preparation for the procedure?

3 :
A nurse is reinforcing teaching about compression stockings with a client. Which of the following client statements indicates an understanding of the teaching

5 :
A nurse is assisting with the care of a client who has pneumonia. Which of the following actions should the nurse take? (Select all that apply.)

6 :
A nurse is participating in discharge planning for a client who has heart failure. Which of the following instructions should the nurse plan to include?

7 :
A nurse is reviewing a client's medical record. Which of the following findings should the nurse recognize as a non-modifiable risk factor for type 2 diabetes mellitus?

8 :
A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse?

9 :
A nurse in a provider's office is talking with a client who takes oxybutynin. The client asks why he does not urinate as often. Which of the following information should the nurse include about the action of oxybutynin?

10 :
A nurse is providing palliative care for a client who is dying. The nurse should expect the provider to prescribe which of the following medications to control excessive oral secretions?

QLexNursing

1 : A nurse is reinforcing teaching with a client who is 24hr postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

2 : A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take in preparation for the procedure?

3 : A nurse is reinforcing teaching about compression stockings with a client. Which of the following client statements indicates an understanding of the teaching

5 : A nurse is assisting with the care of a client who has pneumonia. Which of the following actions should the nurse take? (Select all that apply.)

6 : A nurse is participating in discharge planning for a client who has heart failure. Which of the following instructions should the nurse plan to include?

7 : A nurse is reviewing a client's medical record. Which of the following findings should the nurse recognize as a non-modifiable risk factor for type 2 diabetes mellitus?

8 : A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse?

9 : A nurse in a provider's office is talking with a client who takes oxybutynin. The client asks why he does not urinate as often. Which of the following information should the nurse include about the action of oxybutynin?

10 : A nurse is providing palliative care for a client who is dying. The nurse should expect the provider to prescribe which of the following medications to control excessive oral secretions?

1 :
A nurse is reinforcing teaching with a client who is 24hr postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

2 :
A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take in preparation for the procedure?

3 :
A nurse is reinforcing teaching about compression stockings with a client. Which of the following client statements indicates an understanding of the teaching

5 :
A nurse is assisting with the care of a client who has pneumonia. Which of the following actions should the nurse take? (Select all that apply.)

6 :
A nurse is participating in discharge planning for a client who has heart failure. Which of the following instructions should the nurse plan to include?

7 :
A nurse is reviewing a client's medical record. Which of the following findings should the nurse recognize as a non-modifiable risk factor for type 2 diabetes mellitus?

8 :
A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse?

9 :
A nurse in a provider's office is talking with a client who takes oxybutynin. The client asks why he does not urinate as often. Which of the following information should the nurse include about the action of oxybutynin?

10 :
A nurse is providing palliative care for a client who is dying. The nurse should expect the provider to prescribe which of the following medications to control excessive oral secretions?