Nokea
Which action by the nurse would be most appropriate for a child newly diagnosed with Reye's syndrome?
- A. Determining if the child had a bacterial infection recently
- B. Placing the child in a private room with droplet precautions
- C. Taking the child to the unit's play area to interact with others
- D. Assessing for signs of bleeding and for prolonged bleeding time
Correct Answer: D
Rationale: Assessing for bleeding is critical in Reye's syndrome due to liver dysfunction and potential coagulopathy.
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The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, 'Why do I need to lie on my stomach?' Which statement is the most appropriate statement by the nurse?
- A. This position will help your lungs expand better.'
- B. Lying on your stomach will help prevent contractures.'
- C. Many times this will help decrease pain in the limb.'
- D. The position will take pressure off your backside.'
Correct Answer: B
Rationale: Prone positioning prevents hip flexor contractures post-BKA, promoting mobility. Lung expansion, pain relief, and pressure relief are secondary or unrelated.
To prevent skin breakdown while the client is in Russell's traction, the nurse must frequently inspect the skin in which area?
- A. Over the ischial spines
- B. In the popliteal space
- C. Near the iliac crests
- D. At the zygomatic arch
Correct Answer: B
Rationale: Russell's traction involves a sling under the knee, placing pressure on the popliteal space, which is prone to skin breakdown due to prolonged contact and immobility. Frequent inspection here prevents pressure ulcers.
The physician orders passive range-of-motion (ROM) exercises for an elderly client on bed rest. Which statement regarding the performance of ROM exercises is correct?
- A. ROM exercises should be completed independently with verbal cues from the nurse.
- B. Force may be needed during ROM exercises to achieve maximum benefit.
- C. Support should be maintained to the proximal and distal areas of the joint during movement.
- D. ROM exercises should be performed until the client verbalizes discomfort.
Correct Answer: C
Rationale: Supporting the proximal and distal areas of the joint during passive ROM exercises ensures controlled, safe movement, preventing injury. Independent completion, force, or continuing until discomfort risks harm.
The occupational health nurse is teaching a class on the risk factors for developing osteoarthritis (OA). Which is a modifiable risk factor for developing OA?
- A. Being overweight.
- B. Increasing age.
- C. Previous joint damage.
- D. Genetic susceptibility.
Correct Answer: A
Rationale: Excess weight increases joint stress, a modifiable risk for OA. Age, prior damage, and genetics are nonmodifiable.
Which of the following would the nurse identify as the highest priority when documenting the postoperative circulation status of the recently casted extremity?
- A. Adequate neurovascular functioning
- B. Minimal pain on movement
- C. Vital signs within normal limits
- D. No drainage noted on the cast
Correct Answer: A
Rationale: Adequate neurovascular functioning (circulation, sensation, and movement) is the highest priority to ensure no complications like compartment syndrome or vascular compromise, which can lead to tissue damage. Pain, vital signs, and drainage are secondary.