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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For a client requiring total oral care, it is important for the nurse to:
- A. assemble all equipment, assist the client to semi-Fowler's position, and place a towel on his chest.
- B. place client in Fowler's position, prepare the equipment, and tell the client what to do.
- C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
- D. use gloves and clean the client's mouth, including the tongue.
Correct Answer: C
Rationale: Assemble all equipment first; place the client in a side-lying position so that fluid can easily flow out or pool in the side of the mouth for suctioning (to prevent aspiration); and then place a towel under the client's chin and a curved basin against the chin. Gloves should be worn.
The goals of palliative care include all of the following except:
- A. giving clients with life-threatening illnesses the best quality of life possible.
- B. taking care of the whole person-body, mind, spirit, heart, and soul.
- C. no interventions are needed because the client is near death.
- D. support of needs of the family and client.
Correct Answer: C
Rationale: The goals of palliative care include choices A, B, and D. Choice C is not part of palliative care. All aspects of medical, emotional, social, and spiritual needs of the dying client should be focused on until the end of life.
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.
In teaching clients with Buck's Traction, the major areas of importance should be:
- A. nutrition, ROM exercises.
- B. ROM exercises, transportation.
- C. nutrition, elimination, comfort, safety.
- D. elimination, safety, isotonic exercises.
Correct Answer: C
Rationale: Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids.
The LPN is placing a Foley in a female client. Place the following steps in the appropriate order.A.Prepare the sterile field., B.Separate labia with non-dominant hand., C.Clean the urinary meatus using cleansing solutions and forceps. D. Inflate catheter balloon. E. Place the client in a supine position with flexed knees. F. Place lubricant on catheter. G. Place catheter in meatus with dominant (sterile) hand
- A. E, A, B, F, G, C, D
- B. A, E, B, F, G, D, C
- C. A, E, F, B, C, G, D
- D. E, A, F, B, C, G, D
Correct Answer: D
Rationale: The LPN should follow the correct order of catheter insertion to ensure the catheter is inserted safely. Any other variant of insertion may cause compromise of sterility and client harm.