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A client has scoliosis with a 65-degree curve to the spine. What action by the nurse takes priority?
- A. Allow the client to rest in a position of comfort
- B. Assess the client's cardiac and respiratory systems
- C. Assist the client with ambulating and position changes
- D. Position the client on one side propped with pillows
Correct Answer: B
Rationale: A 65-degree spinal curve in scoliosis can impair cardiac and respiratory function due to chest deformity. Assessing these systems is the priority to ensure the client's safety. Comfort, ambulation, and positioning are important but secondary.
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A client with Paget's disease is hospitalized for an unrelated issue. The client reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Administering pain medication
- B. Applying a heating pad
- C. Providing a massage
- D. Referring the client to a support group
- E. Using a bed cradle to lift sheets off the feet
Correct Answer: B,C
Rationale: Heat and massage are nonpharmacologic comfort measures for Paget's disease pain that can be delegated to a UAP. Administering medication and referrals are nursing responsibilities, and a bed cradle is unnecessary.
A client is admitted with a large draining wound on the leg. What action does the nurse take first?
- A. Administer ordered antibiotics
- B. Insert an intravenous line
- C. Give pain medications if needed
- D. Obtain cultures of the leg wound
Correct Answer: D
Rationale: Obtaining wound cultures is the priority to identify the causative organism before administering antibiotics, which could alter culture results. IV insertion and pain management follow, as they are secondary to accurate diagnosis.
A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best?
- A. Arrange a home safety evaluation
- B. Ensure the client has a walker at home
- C. Schedule daily nursing visits
- D. Refer the client to a support group
Correct Answer: A
Rationale: A home safety evaluation is critical for a client with osteoporosis living alone to reduce fall risks, which can lead to fractures. A walker may not be necessary without assessment, daily visits are excessive, and a support group is secondary to safety.
A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best?
- A. Ask the client about fear of falling
- B. Encourage more calcium intake
- C. Suggest alternative exercises
- D. Teach about weight-lifting techniques
Correct Answer: A
Rationale: Fear of falling can deter clients from performing weight-bearing exercises. Assessing this fear is the first step to address barriers to compliance. Calcium intake, alternative exercises, or weight-lifting techniques may be relevant but are secondary to understanding the client's reluctance.
A client is scheduled for a bone biopsy. What action by the nurse takes priority?
- A. Administering the prescribed oral medication
- B. Answering any questions about the procedure
- C. Ensuring that informed consent is on the chart
- D. Showing the client's family where to wait
Correct Answer: C
Rationale: Ensuring informed consent is on the chart is the priority before a bone biopsy to confirm the client's understanding and agreement to the procedure. Medications, answering questions, and guiding the family are important but secondary.