Nokea
Which of the following actions by the client indicates an understanding of the teaching?
- A. Stepping with his affected leg first when going up stairs
- B. Moving both crutches with the stronger leg forward first
- C. Supporting his body weight while leaning on the axillary crutch pads
- D. Positioning both hands on the grips with his elbows slightly flexed
Correct Answer: D
Rationale: Proper hand positioning ensures effective crutch use.
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A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?
- A. Wear loose-fitting underwear.
- B. Take a bubble bath after intercourse.
- C. Drink four 240 mL(8 oz) glasses of water each day.
- D. Void every 5 to 6 hr during the day.
Correct Answer: A
Rationale: The correct answer is A: Wear loose-fitting underwear. Tight clothing can trap moisture and bacteria, leading to UTIs. Loose-fitting underwear allows for better air circulation, reducing the risk of infection. Choice B is incorrect as bubble baths can irritate the urinary tract. Choice C is important for hydration but not directly related to preventing UTIs. Choice D is good practice for bladder health but does not specifically address UTI prevention.
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?
- A. Tetracycline 200 mg PO
- B. Epoetin alfa 150 units/kg three times weekly
- C. Digoxin 0.25 mg PD dally
- D. Cimetidine PO twice daily
Correct Answer: C
Rationale: The correct answer is C: Digoxin 0.25 mg PO daily. The rationale for this choice being complete is that it includes the medication name (Digoxin), dose (0.25 mg), route of administration (PO - by mouth), and frequency (daily). This prescription is clear and specific, providing all necessary information for the nurse to accurately administer the medication.
Other choices are incorrect:
A: Missing frequency information.
B: Missing route of administration and frequency.
D: Missing dose and frequency.
Which of the following actions should the nurse include in the plan?
- A. Maintain eye contact with the newborn during feedings
- B. Minimize noise in the newborn's environment.
- C. Swaddle the newborn with his legs extended
- D. Administer naloxone to the newborn.
Correct Answer: B
Rationale: Minimizing noise and stimuli helps to reduce symptoms of neonatal abstinence syndrome.
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
- A. Act as a liaison between the facility and the media:
- B. Recommend to the provider specific acute care clients for discharge.
- C. Determine the medical needs of incoming clients through the emergency department
- D. Call in additional medical surgical unit nursing care staff.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The nurse should plan to determine the medical needs of incoming clients through the emergency department during a mass casualty event to prioritize care based on severity. This action allows for efficient allocation of resources and timely treatment for those in critical condition. Acting as a liaison with the media (A) is not a priority during such emergencies. Recommending clients for discharge (B) is inappropriate as the focus should be on incoming patients. Calling in additional staff (D) may be necessary but determining medical needs is the immediate priority.
A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?
- A. Use leading statements to obtain information from the child
- B. Ensure that multiple nurses are present for the physical examination
- C. Explain to the child what will happen when the abuse is reported
- D. Reassure the child that no one will be told about the abuse
Correct Answer: C
Rationale: Correct Answer: C - Explain to the child what will happen when the abuse is reported.
Rationale: It is crucial for the nurse to inform the child about the reporting process to ensure transparency and build trust. This empowers the child and helps them understand the next steps. It also promotes their involvement in decision-making regarding their well-being. By explaining the process, the nurse can offer emotional support and reassurance to the child. This approach respects the child's autonomy and dignity.
Incorrect Choices:
A: Using leading statements can influence the child's responses and compromise the accuracy of information obtained.
B: Having multiple nurses present may intimidate the child and breach confidentiality.
D: Reassuring the child that no one will be told about the abuse may perpetuate feelings of isolation and hinder the necessary intervention.