Nokea
A client is to have an enema to reduce flatus. The enema tube should be inserted:
- A. 4 inches.
- B. 6 inches.
- C. 2 inches.
- D. 8 inches.
Correct Answer: A
Rationale: Enema tubing must be passed beyond the internal sphincter. Two inches is not far enough to pass the internal sphincter. Both 6 and 8 inches are too far and might cause trauma to the bowel.
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The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
- A. Pull the client toward you, and pivot him on the unaffected limb
- B. Pull the client toward you, and pivot him on the affected limb
- C. Push the client toward the bed, and pivot him on the affected limb
- D. Stand the client on both legs, and push him toward the bed
Correct Answer: A
Rationale: Pulling the client and pivoting on the unaffected limb ensures safety and leverages the client's stronger side for support.
While repositioning the client, the LPN notices a shallow, open ulcer on the sacrum with partial-thickness skin loss. What is the classification stage of this ulcer?
- A. Stage I
- B. Stage IV
- C. Stage II
- D. Stage III
Correct Answer: C
Rationale: An ulcer is classified as stage II when the skin is not intact and there is partial-thickness skin loss. An ulcer with full-thickness skin loss would be stage III.
The nurse is caring for the newly admitted male client who is unconscious. The UAP asks if the client should be shaved. What is the nurse's best response?
- A. I need to find out the client's preferences first.
- B. Shave him only after you have bathed him.
- C. Use the electric razor when you shave him.
- D. Avoid shaving him. I need a doctor's order.
Correct Answer: A
Rationale: A: Removal of facial hair varies based on personal and cultural preferences, which should be assessed first. B: Bathing order is irrelevant without preferences. C: Electric razors are safe but preferences are unknown. D: Shaving does not require a doctor's order.
A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
- A. plantar fasciitis.
- B. hallux valgus.
- C. hammertoe.
- D. Morton's neuroma.
Correct Answer: D
Rationale: Morton's neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as a bunion. Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.
The nurse is evaluating the client's ability to perform active ROM. Which illustration demonstrates the client's ability to correctly perform eversion?
- A. eversion_1.PNG
- B. eversion_2.PNG
- C. eversion_3.PNG
- D. eversion_4.PNG
Correct Answer: C
Rationale: C: Eversion is turning the foot outward. A: Shows external rotation. B: Shows internal rotation. D: Shows inversion.