Nokea
A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client?
- A. 1-person stand and pivot with gait belt and walker
- B. 1-person standby assist with walker
- C. 2-person motorized stand-assist lift
- D. 2-person stand and pivot with gait belt and walker
Correct Answer: A
Rationale: A 1-person stand and pivot with a gait belt and walker is appropriate for a client who can partially bear weight and follow instructions. Other methods are either insufficient or overly complex.
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The client has a chest tube attached to a portable water seal drainage system. Four hours after the chest tube is inserted, the nurse notes that there is no bubbling in the water seal compartment. What is the most likely explanation for this?
- A. The lung has reexpanded.
- B. There is an obstruction in the tubing coming from the pleural cavity.
- C. There is an air leak in the drainage system.
- D. The suction is not turned on.
Correct Answer: A
Rationale: No bubbling in the water seal four hours post-insertion suggests the lung has reexpanded, resolving the pneumothorax. Obstruction, air leaks, or inactive suction would typically cause other signs.
The wife of a man who is diagnosed with angina pectoris asks the nurse how she would know if her husband had a heart attack rather than angina. What should the nurse include in the reply?
- A. Crushing chest pain not relieved by nitroglycerin is likely to be a heart attack.
- B. Epigastric pain relieved by antacids is likely to be angina.
- C. Chest pain that does not go down the left arm is usually angina.
- D. Chest pain not associated with activity or excitement is probably angina.
Correct Answer: A
Rationale: Myocardial infarction causes severe chest pain unresponsive to nitroglycerin, unlike angina, which typically resolves. Epigastric pain, arm radiation, or activity triggers are less definitive.
The nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first?
- A. Alert the supervising registered nurse
- B. Check the client's blood pressure and pulse
- C. Listen to the fetal heart rate
- D. Turn the client to a lateral position
Correct Answer: D
Rationale: Symptoms suggest supine hypotensive syndrome; turning the client to a lateral position relieves uterine pressure on the vena cava, improving blood flow.
The client has a cast applied following a fracture of the femur. The doctor tells the nurse to petal the cast. The nurse is aware that he intends for her to:
- A. Cut the cast down both sides.
- B. Cut a window in the cast.
- C. Cover the edges with cast batting.
- D. Cut the cast down one side.
Correct Answer: C
Rationale: Petaling a cast involves covering the rough edges with adhesive tape or cast batting to prevent skin irritation. Cutting the cast or creating a window is a different procedure.
The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which finding requires priority action?
- A. Blood-tinged stain on the inner aspect of the cast
- B. Capillary refill of 2 seconds on the affected extremity
- C. Mild swelling of toes on the right foot
- D. Pain of 9/10 an hour after a dose of morphine
Correct Answer: D
Rationale: Severe pain (9/10) despite recent morphine suggests complications like compartment syndrome, requiring immediate action. Other findings are less urgent.