Nokea
A client is recovering from a stroke and the nurse is doing range-of-motion exercises. Which movements should be included for ROM of the elbow on the weak side? Select all that apply.
- A. Abduction and adduction
- B. Hyperextension
- C. Supination and pronation
- D. Flexion and extension
- E. Rotation
Correct Answer: C,D
Rationale: Elbow ROM includes supination/pronation (C) and flexion/extension (D). Abduction/adduction (A), hyperextension (B), and rotation (E) are not applicable to the elbow joint.
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A client admitted for treatment of a deep venous thrombosis of the calf complains of dyspnea and chest pain. What is the best response by the nurse?
- A. administer oxygen at 2 L/min as ordered prn
- B. place client in a semi-Fowler's position
- C. prepare client for diagnostic tests
- D. obtain vital signs
Correct Answer: C
Rationale: Dyspnea and chest pain suggest a possible pulmonary embolism, a complication of DVT, requiring immediate preparation for diagnostic tests to confirm and treat.
The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?
- A. Notifying the physician
- B. Performing tracheal suctioning
- C. Repositioning the client to the left side
- D. Rechecking the client's O2 saturation
Correct Answer: B
Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.
An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching plan, the nurse should initially assess:
- A. The client's knowledge of the signs of preterm labor
- B. The client's feelings about the pregnancy
- C. Whether the client was using a method of birth control
- D. The client's thought about future children
Correct Answer: B
Rationale: Assessing the client's feelings about the pregnancy is critical at 10 weeks to tailor education and support to her emotional needs.
The nurse has rounded on all the assigned clients. While rounding, several health care providers have written orders on the nurse's clients. Which order would be the priority for the nurse to address?
- A. furosemide (Lasix) 80 mg IV push STAT for a client with fluid overload
- B. a new insulin sliding scale for a client with a glucose level of 242
- C. perform a dressing change on a client with a stage 2 diabetic foot ulcer
- D. discharge a client who was admitted for removal of an abdominal abscess
Correct Answer: A
Rationale: STAT orders for furosemide address acute fluid overload, a potentially life-threatening condition, making it the priority over insulin, dressing changes, or discharge.
The nurse is teaching a female client who is experiencing urge incontinence how to manage her condition at home. Which statement by the client indicates a need for further explanation by the nurse?
- A. I will be cured in four weeks if I follow the bladder retraining instructions.
- B. I will perform the pelvic muscle exercises daily.
- C. I will wait five minutes once I get the urge to urinate to go to the bathroom.
- D. I will empty my bladder when I first get up in the morning.
Correct Answer: A
Rationale: Urge incontinence may not be cured in four weeks; bladder retraining aims to manage symptoms, not guarantee a cure, indicating a need for further teaching.