Nokea
A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for reinforcement of teaching?
- A. Faces forward when going up and down the stairs
- B. Holds the cane with the right hand
- C. Leads with left leg, follows next with cane, and finally right leg when going up the stairs
- D. Places full weight on left leg when going down the stairs
Correct Answer: D
Rationale: Placing full weight on the surgical leg when going down stairs risks injury and instability. The client should lead with the cane and unaffected leg, using the surgical leg cautiously.
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Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct Answer: D
Rationale: Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2 years of age, and meticulous combing and removal of all nits.
The physician has recommended that an adult male be scheduled for a left heart catheterization. The client asks the nurse what a cardiac catheterization is for. What information should be included when responding to this client?
- A. During a left heart catheterization, the coronary arteries can be visualized.
- B. During a left heart catheterization, holes in the heart walls can be detected.
- C. During a left heart catheterization, blood flow to the lungs can be measured.
- D. During a left heart catheterization, oxygen levels in the chambers of the heart are measured.
Correct Answer: A
Rationale: Left heart catheterization visualizes coronary arteries to assess for blockages, aiding in diagnosing coronary artery disease.
Which one of these tasks can be safely delegated to a practical nurse (PN)?
- A. Assess the function of a newly created ileostomy
- B. Care for a client with a recent complicated double barrel colostomy
- C. Provide stoma care for a client with a well functioning ostomy
- D. Teach ostomy care to a client and their family members
Correct Answer: C
Rationale: Provide stoma care for a client with a well functioning ostomy. The care of a mature stoma and the application of an ostomy appliance may be delegated to a PN. This client has minimal risk of instability of the situation.
The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required?
- A. I need to have the entire house treated by pest control to ensure the bed bugs are gone.
- B. I should concentrate on alleviating scratching as it can cause further complications.
- C. My other family members and pets are at risk of bed bug bites.
- D. This must have happened because I did not wash the bed sheets this week.
Correct Answer: D
Rationale: Bed bug infestations are not caused by unwashed sheets but by exposure to infested environments. This misconception indicates a need for further teaching about bed bug transmission and prevention.