Nokea
The hydraulic lift (Hoyer lift) is:
- A. used for all clients who've had orthopedic surgery.
- B. used for all clients who are not able to stand and for extremely obese clients.
- C. used for all clients, both old and young, in a hospital setting.
- D. not an assistive device for special needs.
Correct Answer: B
Rationale: The hydraulic lift is used for safe transfer when a client is not able to stand or is too heavy for the health care workers to lift safely.
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An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?
- A. inability to turn, cough, and breathe deeply
- B. inability to communicate pain
- C. inability to ambulate freely
- D. inability to use a bedside commode
Correct Answer: B
Rationale: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client.
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:
- A. notify the physician of the drainage.
- B. change the dressing.
- C. reinforce the dressing.
- D. apply an abdominal binder.
Correct Answer: C
Rationale: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.
A nurse is assessing a 18 year-old female who has recently suffered a TBI. The nurse should report these findings immediately to the physician, due to the possibility the patient is experiencing which of the following conditions?
- A. Increased intracranial pressure
- B. Increased function of cranial nerve X
- C. Sympathetic response to activity
- D. Meningitis
Correct Answer: A
Rationale: The patient is at high risk of developing increased intracranial pressure (ICP) due to the traumatic brain injury, which can cause a slower pulse and impaired respiration.
In managing nausea related to Morphine epidural analgesia, the nurse should administer:
- A. Indocin
- B. Codeine
- C. Motrin
- D. Compazine
Correct Answer: D
Rationale: Compazine (prochlorperazine) is an antiemetic effective for opioid-induced nausea, unlike the other options, which are analgesics or anti-inflammatories.
The nurse is observing the UAP prepare a shower for the client who requires assistance with ambulation and hygiene. Which action(s) by the UAP indicate understanding of the procedure? Select all that apply.
- A. Sets the water temperature at 100° to 105° F (37° to 40° C).
- B. Locks the door to provide the client with privacy.
- C. Uses a chair for the client to sit on in the shower.
- D. Ensures a nonskid surface is in the shower.
- E. Helps to wash areas the client cannot reach.
Correct Answer: C,D,E
Rationale: C: A shower chair prevents falls for a client with ambulation issues. D: A nonskid surface enhances safety. E: Assisting with hard-to-reach areas supports hygiene. A: Water should be 110°-115°F for comfort. B: Locking the door is unsafe for a client needing assistance.