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Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
- A. Raise the head of the client's bed to a high-fowlers position.
- B. Elevate the clients effected leg on a pillow when in bed.
- C. Position the clients knees slightly higher than the hips when up in a chair
- D. Keep an abduction pillow between the client's legs.
Correct Answer: D
Rationale: The correct answer is D: Keep an abduction pillow between the client's legs. This helps maintain proper alignment and prevents excessive internal rotation of the hip, reducing the risk of dislocation. Elevating the affected leg on a pillow (B) may not provide adequate support. Raising the head of the bed to a high-fowlers position (A) and positioning the knees higher than the hips (C) do not directly address hip alignment.
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Which of the following responses should the nurse make?
- A. Tell me what concerns you about the bedpan
- B. Make sure to use nearby furniture to support yourself when walking to the bathroom.
- C. I will have the physical therapist ambulate you to the bathroom.
- D. You have to use the bedpan for your own safety.
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you about the bedpan." This response demonstrates active listening and empathy, allowing the nurse to understand the patient's specific worries or fears. It promotes patient-centered care by addressing the individual's needs. Other options lack this patient-centered approach: B assumes the patient can walk, C delegates without assessing the patient's concerns, and D is directive and dismissive of the patient's feelings.
Which of the following actions should the nurse take first?
- A. Encourage the family to assign specific tasks to individual family members.
- B. Determine the roles of individual family members.
- C. Assist the family to establish a daily routine
- D. Refer the family to a grief support group.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because it helps identify the strengths and abilities of each family member, allowing for effective delegation of tasks and responsibilities. By understanding each member's role, the nurse can promote a balanced distribution of duties and enhance the family's ability to cope with the situation. Encouraging the family to assign specific tasks (A) may be premature without knowing each member's capabilities. Establishing a daily routine (C) can come after roles are determined to provide structure. Referring to a grief support group (D) may be necessary but not the first step.
Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who has a prescription for compression stockings and did not receive them.
- B. A client who requests assistance in ambulating to the restroom.
- C. A client who ate 50% of their lunch tray.
- D. A client whose blood pressure is 88/52 mmHg.
Correct Answer: D
Rationale: The correct answer is D. A blood pressure of 88/52 mmHg is considered hypotensive and requires immediate attention. The nurse should instruct the AP to report this vital sign reading to the nurse for further assessment and intervention to prevent complications such as hypoperfusion to vital organs. Choices A, B, and C do not pose immediate life-threatening risks and can be addressed during routine care. Choice D stands out as the priority due to the potential for serious consequences if not addressed promptly.
Which of the following manifestations should the nurse expect?
- A. Fever
- B. Bradycardia
- C. Dry skin
- D. Decreased respiratory rate
Correct Answer: A
Rationale: The correct answer is A: Fever. When the body is fighting an infection or inflammation, fever is a common manifestation due to the release of pyrogens that reset the body's temperature. Bradycardia (B) is a slow heart rate, not typically associated with infection. Dry skin (C) is more indicative of dehydration or a skin condition. Decreased respiratory rate (D) is not a common manifestation of infection. In this case, fever is the most expected manifestation due to the body's response to an infection.
Which of the following prescriptions should the nurse clarify?
- A. Digoxen 250 PO daily
- B. Metoprolol 50 mg PO twice daily
- C. Furosemide 40 mg IV once daily
- D. Acetaminophen 650 mg PO every 6 hours PRN pain
Correct Answer: A
Rationale: The correct answer is A. Digoxin is commonly prescribed in mcg, not mg. Therefore, the nurse should clarify the dosage unit. Metoprolol (B) is a typical dose and frequency for oral administration. Furosemide (C) is a standard dose and route for IV administration. Acetaminophen (D) is a common dose and frequency for pain management. The other choices are not problematic.