Nokea
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
- A. Thermometer
- B. Elastic stockings
- C. Blood pressure cuff
- D. Sequential compression devices
Correct Answer: C
Rationale: The correct answer is C: Blood pressure cuff. To assess for orthostatic hypotension, the nurse needs to measure the patient's blood pressure in different positions - lying down, sitting, and standing. This is done using a blood pressure cuff to monitor any significant drop in blood pressure upon changing positions. A thermometer (choice A) is used to measure temperature and is not relevant to assessing orthostatic hypotension. Elastic stockings (choice B) are used for compression therapy in conditions like venous insufficiency and do not help in assessing orthostatic hypotension. Sequential compression devices (choice D) are used for preventing deep vein thrombosis and improving circulation, not for assessing orthostatic hypotension.
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Nurse on peds unit is caring for adolescent with multiple fractures. Which interventions are appropriate for client? (Select all that apply.)
- A. Suggest his parents room in with him
- B. Provide a TV & DVDs for him to watch
- C. Limit visitors to immediate family
- D. Devise a regular schedule for inpatient routines
- E. Allow him to perform his own morning care
Correct Answer: B,E
Rationale: The correct choices are B and E. Providing a TV & DVDs and allowing the adolescent to perform his own morning care are appropriate interventions for the client's care. Offering entertainment can help with psychological well-being. Allowing independence in self-care promotes autonomy and self-esteem. Choice A may not be appropriate for an adolescent seeking independence. Choice C may restrict emotional support from close friends. Choice D is important but not the most crucial in this scenario.
Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which client should be assigned to room closest to the nursing station?
- A. 43-year-old client post-op following laparoscopic cholecystectomy
- B. 61-year-old client being admitted for telemetry to rule out MI
- C. 50-year-old client post-op following open reduction internal fixation of ankle
- D. 79-year-old client post-op following below-the-knee amputation
Correct Answer: D
Rationale: The correct answer is D. The 79-year-old client post-op following below-the-knee amputation should be assigned to the room closest to the nursing station for fall prevention. This is because this client may have mobility challenges and an increased risk of falls due to the recent surgery and potential use of assistive devices. Placing the client closer to the nursing station allows for closer monitoring and quicker assistance in case of any fall-related incidents.
Choice A is incorrect because a 43-year-old client post-op following laparoscopic cholecystectomy is not necessarily at an increased risk for falls related to mobility issues.
Choice B is incorrect as a 61-year-old client being admitted for telemetry to rule out MI is not specifically at a higher risk for falls compared to the client post-amputation.
Choice C is incorrect as a 50-year-old client post-op following open reduction internal fixation of the ankle may have mobility limitations, but the risk of falls is typically lower compared to a client post
Nurse transferring client from acute-care hospital to rehab facility. Which of following info about client should nurse include in transfer report?
- A. Alert & oriented
- B. Refuses to eat spinach
- C. Has shellfish allergy
- D. Requests morphine every 4h
- E. Misses the 2 cats he has at home
- F. allergies
- G. Alertness
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A - Being alert and oriented is crucial for the client's safety and care continuity. C - Shellfish allergy is critical to prevent adverse reactions. D - Morphine request indicates pain management needs. Incorrect choices: B - Food preference is not a priority in transfer report. E - Missing pets is not pertinent medical information. F, G - General terms without specific details are not essential for transfer report.
A nurse is assessing body alignment. What is the nurse monitoring?
- A. The relationship of one body part to another while in different positions
- B. The coordinated efforts of the musculoskeletal and nervous systems
- C. The force that occurs in a direction to oppose movement
- D. The inability to move about freely
Correct Answer: A
Rationale: The correct answer is A. The nurse is monitoring the relationship of one body part to another while in different positions to ensure proper alignment. This is crucial for preventing musculoskeletal issues. Choice B refers to coordination, not body alignment. Choice C refers to resistance, not alignment. Choice D refers to immobility, not alignment.
Nurse evaluating how well client learned the info presented in teaching about heart-healthy diet. Client states she understands what to do now. Which actions by nurse should assist evaluation of client's learning?
- A. Encourage client to ask questions
- B. Ask client to explain how to select or prepare meals
- C. Encourage client to fill out eval form
- D. Ask client if she has resources for further instruction on topic
Correct Answer: B
Rationale: The correct answer is B: Ask client to explain how to select or prepare meals. This action allows the nurse to assess the client's understanding of the heart-healthy diet by evaluating their ability to articulate the key concepts and apply them practically. By explaining the process of selecting or preparing meals, the client demonstrates comprehension and application of the information provided during the teaching session. Encouraging questions (choice A) is important but may not directly assess the client's ability to implement the information. Encouraging the client to fill out an evaluation form (choice C) focuses more on feedback rather than assessing learning. Asking about additional resources (choice D) is relevant but doesn't directly assess the client's understanding of the heart-healthy diet.