Nokea
A client is having problems with her ankles. To assess her ankles' ROM, which ROM exercises should the nurse have her perform?
- A. flexion, extension, hyperextension
- B. flexion, extension, abduction, adduction
- C. external rotation, internal rotation
- D. extension, flexion, inversion, eversion
Correct Answer: D
Rationale: Ankle range of motion includes extension, flexion, inversion, and eversion, assessing the joint's full functional capacity.
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Which of the following is least important to test when assessing the client's motor skills?
- A. strength
- B. knowledge of ergonomics
- C. balance
- D. coordination
Correct Answer: B
Rationale: When assessing a client's motor skills, testing the client's strength, balance and coordination are most important. The client's knowledge of ergonomics is less relevant.
A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?
- A. shopping for groceries
- B. house cleaning
- C. transportation to physician's visits
- D. medication instruction
Correct Answer: D
Rationale: The only skilled service listed is medication instruction. Grocery shopping, house-cleaning services, and transportation services are all examples of unskilled services offered by volunteer and fee-for-service agencies.
The hospitalized client with limited mobility is at risk for skin breakdown. Which interventions should the nurse include in the plan of care to maintain the client's skin integrity? Select all that apply.
- A. Massage vigorously over bony prominences daily
- B. Wear sterile gloves when inspecting the client's skin
- C. Apply a moisturizing lotion to bony prominences
- D. Instruct the client to change position every 2 hours
- E. Apply an overhead trapeze to the client's bed
- F. Apply a barrier cream if the client is incontinent of stool
Correct Answer: C,D,E,F
Rationale: C: Moisturizers prevent dry skin. D: Repositioning improves circulation. E: Trapezes reduce friction during movement. F: Barrier creams protect against incontinence. A: Vigorous massage causes tissue trauma. B: Sterile gloves are unnecessary unless breakdown exists.
The nurse is assessing the client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding requires immediate intervention by the nurse?
- A. Nasogastric tube to low intermittent suction has small amounts of dark bloody returns.
- B. Oxygen saturation level is 92%, and oxygen by nasal cannula is set at 2 liters.
- C. The incisional dressing has a 25-cent-piece-sized shadow of new drainage.
- D. The Jackson-Pratt drain is round in shape with 30 mL serosanguineous drainage.
Correct Answer: D
Rationale: D: A round JP drain indicates lost suction, requiring immediate emptying and compression. A: Minor bloody NG returns are normal post-surgery. B: 92% saturation is adequate. C: Small drainage is monitorable.
The nurse is turning a client who has a new prosthetic hip. Which position should be avoided to prevent injury to the new prosthetic hip?
- A. abduction of the hip
- B. adduction of the hip
- C. flexing the hip at 80° flexion
- D. flexing the hip at 90°
Correct Answer: B
Rationale: New prosthetic hips should have an abduction pillow in place to avoid adduction.