Nokea
A client who is paraplegic cannot feel her lower extremities and has been positioned on her side. The nurse should inspect which of the following areas that is a potential pressure point when the client is in this position?
- A. Sacrum.
- B. Occiput.
- C. Ankles.
- D. Heel.
Correct Answer: C
Rationale: When side-lying, the ankles are a common pressure point due to prolonged contact with the bed. The sacrum, occiput, and heel are more at risk in other positions like supine.
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A client with a history of rheumatoid arthritis is prescribed hydroxychloroquine (Plaquenil). The nurse should instruct the client to:
- A. Have regular eye exams.
- B. Take the medication on an empty stomach.
- C. Avoid calcium-rich foods.
- D. Stop the medication if joint pain resolves.
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity, requiring regular eye exams.
Which of the following correctly describes Medicaid?
- A. A program designed to assist ill, low-income older adults.
- B. A federal insurance program for pregnant women.
- C. A joint federal-state program for low-income persons.
- D. A program administered by health maintenance organizations.
Correct Answer: C
Rationale: Medicaid is a joint federal-state program providing healthcare coverage for low-income individuals, including children, pregnant women, and the elderly.
The nurse is assessing a teenage girl. According to the fi gure below, the nurse should note that the girl has:
- A. Kyphosis.
- B. Arthritis.
- C. Developmental dysplasia of the hip.
- D. Scoliosis.
Correct Answer: D
Rationale: The teenage girl has scoliosis, the lateral deviation of the spine. Kyphosis is noted by a forward curvature of the shoulders. Arthritis is diagnosed by radiographs. Hip dysplasia is noted in older children by pain, but is usually diagnosed before the child walks by noting excessive gluteal folds and limited hip abduction.
When teaching unlicensed assistive personnel (UAP) about the importance of hand washing in preventing disease, the nurse should instruct the UAP that?
- A. It is not necessary to wash your hands as long as you use gloves.'
- B. Handwashing is the best method for preventing cross-contamination.'
- C. Waterless commercial products are not effective for killing organisms.'
- D. The hands do not serve as a source of infection.'
Correct Answer: B
Rationale: Handwashing is the most effective method to prevent cross-contamination, as hands are a primary source of infection transmission in healthcare settings.
A client has a cerclage placed at 16 weeks' gestation. She has had no contractions and her cervix is dilated 2 cm. The nurse is preparing the client for discharge. Which statement by the client should indicate to the nurse that the client needs further instruction?
- A. I will need more frequent prenatal visits.'
- B. I should call if I am leaking fluid or have bleeding or contractions.'
- C. I can have sex again in about 2 weeks.'
- D. I can have nothing in my vagina until I am at term.'
Correct Answer: C
Rationale: Sexual intercourse is typically contraindicated after cerclage until term to prevent complications. The other statements reflect correct understanding of cerclage care.