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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A nurse is reinforcing appropriate interventions with the parent of an infant who had a febrile seizure. Which instruction is appropriate to review?
- A. Give acetaminophen or ibuprofen every 6-8 hours to control fever.
- B. Give the infant frequent tepid sponge baths to control the fever.
- C. If the infant develops another seizure, wait 15 minutes to see if it subsides.
- D. Place ice bags under the arms and around the neck to control fever.
Correct Answer: A
Rationale: Administering acetaminophen or ibuprofen every 6-8 hours helps control fever, reducing the risk of recurrent febrile seizures in infants.
The nurse is reinforcing teaching with an adolescent client who has acne vulgaris. Which of the following information should the nurse reinforce? Select all that apply.
- A. A well-balanced diet can help support healthy skin.
- B. Antibacterial soap is harsh and can make your acne worse.
- C. Scrub whiteheads vigorously when washing your face twice daily.
- D. Squeezing or picking the lesions may increase the risk for infection and scarring.
- E. Use skin care products labeled as noncomedogenic to avoid clogging your skin pores.
Correct Answer: A,B,D,E
Rationale: A balanced diet (A), avoiding harsh soaps (B), not picking lesions (D), and using noncomedogenic products (E) promote skin health and prevent acne exacerbation.
The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to 'reach the itch.' What is the nurse's priority action?
- A. Offer the client a straw to reach the itch instead of a lead pencil
- B. Perform a peripheral neurovascular check of the casted extremity
- C. Pour a generous amount of baby powder or corn starch in the cast to reach the itch
- D. Review appropriate itch relief technique using the cool setting of a hair dryer
Correct Answer: D
Rationale: Using a hair dryer on a cool setting is a safe and effective way to relieve itching without risking skin damage or cast integrity, unlike inserting objects or powders.
The nurse is caring for assigned clients. The nurse should first check the client
- A. with hypothyroidism who is reporting constipation, weakness, and peripheral edema
- B. with chronic pancreatitis who is reporting upper abdominal pain and voluminous, foul-smelling, fatty stools
- C. who has bacterial pneumonia, is receiving IV antibiotic therapy, and is reporting a cough productive of blood-tinged sputum
- D. who has an external fixation device, a temperature of 101.8°F (38.8°C), and is reporting redness and pain around the pin sites
Correct Answer: D
Rationale: Fever, redness, and pain around pin sites suggest a possible infection at the external fixation site, which is a priority due to the risk of osteomyelitis or systemic infection.
The nurse is reinforcing teaching to an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply.
- A. Eating a high-protein snack at bedtime
- B. Limiting alcohol intake
- C. Losing weight
- D. Taking a mild sedative at bedtime
- E. Taking a nap during the day
- F. Taking modafinil at bedtime
Correct Answer: B,C
Rationale: Limiting alcohol (B) reduces airway relaxation, and losing weight (C) decreases airway obstruction, both directly alleviating sleep apnea symptoms.