Nokea
A client had a left hip arthroplasty. Which of the following interventions should the nurse use to prevent dislocation?
- A. Maintain foam wedge between legs
- B. Monitor for shortening of the affected leg
- C. Encourage use of elastic stockings
- D. Avoid flexing the hips more than 60 degrees
Correct Answer: A
Rationale: The correct answer is to maintain a foam wedge between the legs. This intervention helps prevent hip dislocation by maintaining proper leg alignment after surgery. Monitoring for shortening of the affected leg (choice B) is not directly related to preventing dislocation. Encouraging the use of elastic stockings (choice C) is more related to preventing deep vein thrombosis rather than dislocation. Avoiding flexing the hips more than 60 degrees (choice D) is important post-surgery, but it is not the most direct intervention to prevent dislocation.
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A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
- A. Self-report of pain
- B. Nonverbal behavior
- C. Severity of the condition
- D. Vital signs
Correct Answer: A
Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Inject at a 90-degree angle
- B. Inject at a 45-degree angle
- C. Massage the injection site after administering
- D. Use a longer needle
Correct Answer: B
Rationale: The correct answer is to inject enoxaparin subcutaneously at a 45-degree angle. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Option A (Inject at a 90-degree angle) is incorrect because subcutaneous injections are usually given at a shallower angle. Option C (Massage the injection site after administering) is incorrect as massaging the site can cause bruising and should generally be avoided. Option D (Use a longer needle) is incorrect as using a longer needle is unnecessary and may increase the risk of injecting the medication too deeply.
A client is being taught about which foods to include in a low fiber diet. Which statement indicates understanding?
- A. Choosing a fresh pear would be a good snack option
- B. I should make refried beans for supper
- C. Selecting white rice as a side dish is a good choice
- D. Opting for bran cereal would be a good breakfast choice
Correct Answer: C
Rationale: The correct answer is C because white rice is a low-fiber food suitable for a low-fiber diet, making it an appropriate choice. Choices A, B, and D are incorrect because fresh pear, refried beans, and bran cereal are high-fiber foods and not suitable for a low-fiber diet.
A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?
- A. Cleanse the bag every 24 hours
- B. Cleanse the bag every 48 hours
- C. Use tap water
- D. Flush the tube every 4 hours
Correct Answer: A
Rationale: The correct answer is A. Cleansing the bag every 24 hours can lead to contamination, increasing the risk of infection and diarrhea. Using tap water (choice C) is not recommended for cleaning the gastrostomy tube due to the risk of introducing harmful microorganisms. Cleansing the bag every 48 hours (choice B) is not frequent enough and may also contribute to infection. Flushing the tube every 4 hours (choice D) is a standard practice to ensure patency and should not be intervened by the nurse.
A client has a prescription for vancomycin 1g IV intermittent infusion over 30 minutes every 12 hours. What action should the nurse take?
- A. Start the infusion immediately
- B. Slow down the infusion rate
- C. Contact the provider for prescription clarification
- D. Check blood pressure during the infusion
Correct Answer: C
Rationale: The correct action for the nurse to take is to contact the provider for prescription clarification. Administering vancomycin over less than 60 minutes can lead to infusion reactions like hypotension and flushing. Starting the infusion immediately (choice A) is incorrect as it goes against the prescribed rate. Slowing down the infusion rate (choice B) without provider approval can result in underdosing the medication. Checking blood pressure during the infusion (choice D) is important but not the most immediate action needed in this situation.