Nokea
A client is being assisted to lie in the Sims' position. In what position does the nurse arrange the client?
- A. The client lies on his side with the upper leg flexed
- B. The client lies on his back with his head lower than his feet
- C. The client lies on his abdomen with a pillow supporting his head
- D. The client is sitting up at a 90-degree angle
Correct Answer: A
Rationale: The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg. Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet. Choice C is incorrect as it describes a prone position, not the Sims' position. Choice D is incorrect as it describes a sitting position, not the Sims' position.
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A client is preparing to irrigate a colostomy. Which of the following situations is a contraindication for this type of irrigation?
- A. The client has an incontinent ostomy
- B. The client has an irregular bowel routine
- C. The client has diverticulitis
- D. The colostomy bag contains fecal material
Correct Answer: C
Rationale: When a client with a colostomy is preparing for irrigation, it is essential to consider contraindications that could pose risks or worsen the client's condition. Diverticulitis is a contraindication for colostomy irrigation because the inflamed diverticula could be further irritated by the flushing action during irrigation, potentially leading to complications. An incontinent ostomy, irregular bowel routine, or presence of fecal material in the colostomy bag are not specific contraindications for irrigation and can be managed through appropriate techniques and interventions.
Which of the following statements best describes footdrop?
- A. The foot is permanently fixed in the dorsiflexion position
- B. The foot is permanently fixed in the plantar flexion position
- C. The toes of the foot are permanently fanned
- D. The heel of the foot is permanently rotated outward
Correct Answer: B
Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.
A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?
- A. The client most likely has a mental illness that should be treated before addressing sleep issues
- B. The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
- C. The client may become tired once they start talking
- D. None of the above
Correct Answer: B
Rationale: Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.
Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?
- A. Perform nursing activities throughout the entire shift
- B. Assess for signs of increased muscle tone
- C. Minimize environmental noise
- D. Teach clients to perform the Valsalva maneuver
Correct Answer: C
Rationale: The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.
A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?
- A. Administer the feeding as ordered
- B. Pull the feeding tube out approximately 3 cm
- C. Flush the feeding tube with 60 cc of water
- D. Contact the physician
Correct Answer: A
Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.