Nokea
A client is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?
- A. Encourage the client to bend at the waist
- B. Maintain the client in a high-Fowler's position
- C. Place a pillow between the client's legs
- D. Avoid placing a pillow under the client's knees
Correct Answer: C
Rationale: Placing a pillow between the client's legs is beneficial after hip replacement surgery to maintain proper alignment and prevent dislocation of the prosthesis. This position helps keep the hip in a neutral position, reducing the risk of dislocation. Encouraging the client to bend at the waist (Choice A) can increase the risk of hip dislocation. Maintaining the client in a high-Fowler's position (Choice B) and avoiding placing a pillow under the client's knees (Choice D) do not directly address the need to maintain proper alignment of the hip joint to prevent dislocation.
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A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Administer the medication into the client's nondominant arm.
- B. Pull the skin laterally before inserting the needle.
- C. Massage the injection site after administration.
- D. Pinch the skin between the thumb and forefinger.
Correct Answer: D
Rationale: The correct action the nurse should take when administering enoxaparin subcutaneously is to pinch the skin between the thumb and forefinger. Pinching the skin helps to lift the subcutaneous tissue, reducing the risk of injecting into the muscle. Choices A, B, and C are incorrect. Choice A is not relevant as the injection site for enoxaparin is typically in the abdomen or thigh, not the arm. Choice B is incorrect as pulling the skin laterally is not a recommended technique for subcutaneous injections. Choice C is also incorrect as massaging the injection site after administration can increase the risk of bleeding or bruising.
A client needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?
- A. I had a bowel movement, but I was able to save the urine.
- B. I have a specimen in the bathroom from about 30 minutes ago.
- C. I flushed what I urinated at 7 am and have saved the rest since.
- D. I drink a lot, so I will fill up the bottle and complete the test quickly.
Correct Answer: C
Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. The roommate is up independently
- B. The client ambulates with his slippers on over his antiembolic stockings
- C. The client uses a front-wheeled walker when ambulating
- D. The client had pain meds 30 minutes ago
Correct Answer: C
Rationale: The correct answer is C. After knee arthroplasty, it is essential for the client to use a front-wheeled walker when ambulating to ensure stability and prevent falls. Sharing this information with the assistive personnel (AP) is crucial for the client's safety and proper rehabilitation. Choices A, B, and D are incorrect because the roommate's independence, the client's footwear over stockings, and the timing of pain medication administration are not directly related to the safe ambulation of a client post-knee arthroplasty.
What is the most important nursing action when administering IV potassium?
- A. Monitor for decreased urine output
- B. Administer via IV push
- C. Administer slowly and dilute in IV fluids
- D. Ensure the client drinks 500 mL of water before administration
Correct Answer: C
Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.
A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?
- A. Continue to monitor the fetal heart rate.
- B. Stop the oxytocin infusion.
- C. Perform a vaginal examination.
- D. Initiate an amnioinfusion.
Correct Answer: A
Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.