Nokea
A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?
- A. shopping for groceries
- B. house cleaning
- C. transportation to physician's visits
- D. medication instruction
Correct Answer: D
Rationale: The only skilled service listed is medication instruction. Grocery shopping, house-cleaning services, and transportation services are all examples of unskilled services offered by volunteer and fee-for-service agencies.
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The nurse is turning a client who has a new prosthetic hip. Which position should be avoided to prevent injury to the new prosthetic hip?
- A. abduction of the hip
- B. adduction of the hip
- C. flexing the hip at 80° flexion
- D. flexing the hip at 90°
Correct Answer: B
Rationale: New prosthetic hips should have an abduction pillow in place to avoid adduction.
Before ambulating the client for the first time, the nurse obtains the client's BP with an automatic BP machine. Which actions should the nurse take first when obtaining a BP reading of 86/56 mm Hg and pulse rate of 64 bpm?
- A. Assess the client for dizziness and feel the temperature of extremities
- B. Obtain a manual BP cuff and machine and retake the client's BP
- C. Elevate the head of the client's bed and assist the client out of bed
- D. Review the medical record and determine the client's normal BP range
Correct Answer: A
Rationale: A: Assessing for hypotension symptoms like dizziness or cold extremities is priority. B: Retaking BP follows assessment. C: Ambulating risks falls with hypotension. D: Reviewing records is secondary.
A client is having problems with her ankles. To assess her ankles' ROM, which ROM exercises should the nurse have her perform?
- A. flexion, extension, hyperextension
- B. flexion, extension, abduction, adduction
- C. external rotation, internal rotation
- D. extension, flexion, inversion, eversion
Correct Answer: D
Rationale: Ankle range of motion includes extension, flexion, inversion, and eversion, assessing the joint's full functional capacity.
The client who is Jewish is to receive a kosher meal. Which direction by the nurse to the NA is appropriate?
- A. Avoid eye contact when delivering the meal tray.
- B. Do not remove the wrapping from the plastic utensils.
- C. Have the client sit for the meal facing toward Mecca.
- D. Check that the meal contains both milk and kosher meat.
Correct Answer: B
Rationale: B: Unwrapped utensils ensure kosher compliance. A: Eye contact is not restricted. C: Facing Mecca is a Muslim practice. D: Kosher meals separate dairy and meat.
A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO0. How many milliliters of fluid did the patient ingest?
- A. $440 \mathrm{ml}$
- B. $480 \mathrm{ml}$
- C. $22 \mathrm{ml}$
- D. $660 \mathrm{ml$
Correct Answer: B
Rationale: 1 ounce = 30 ml, so Juice, 6 ounces (half of 12 oz) × 30 = 180 ml (Remember that oz is an abbreviation for ounces.) Soup, 4 ounces × 30 = 120 ml JELL-OB, 6 ounces × 30 = 180 ml 180 + 120 + 180 = 480 ml Note that gelatin, ice cream, and other things that are liquid at room temperature are counted as fluids.