Nokea
A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?
- A. The client moves the walker ahead 25.4 cm with each step
- B. The client picks up the walker with each step
- C. The client stands with elbows slightly bent while holding the walker
- D. The client stoops slightly forward when moving the walker
Correct Answer: C
Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.
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A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement when working with the client?
- A. Airborne
- B. Droplet
- C. Protective
- D. Contact
Correct Answer: A
Rationale: Tuberculosis is an infectious disease that requires airborne precautions to prevent the transmission of infectious droplets. Airborne precautions involve wearing a mask, such as an N95 respirator, to protect against inhaling infectious particles. Droplet precautions are for diseases spread through respiratory droplets larger than those in airborne transmission, such as influenza. Protective precautions are not specific to respiratory infections and are more general measures to protect patients from harm. Contact precautions are used for diseases spread by direct or indirect contact, such as MRSA or C. diff infections, not for tuberculosis.
During an admission assessment for an older adult client, what is the priority action for the nurse after gathering data and reviewing systems?
- A. Orient the client to their room.
- B. Conduct a client care conference.
- C. Review medical prescriptions.
- D. Develop a plan of care.
Correct Answer: A
Rationale: The priority action for the nurse after completing the assessment and review of systems for an older adult client is to orient them to their room. This is crucial for ensuring the client's comfort and safety in the new environment. While reviewing medical prescriptions and developing a plan of care are important aspects of the admission process, they can be done after the client has been oriented to their room.
A client who is terminally ill has a family member who is coping effectively with the situation. Which of the following statements should the nurse identify as an indication of effective coping?
- A. "We still have hope that everything will be okay."
- B. "This is a difficult time, but we are helping each other through this."
- C. "After he comes home, we can plan out a family reunion."
- D. "We don't need to talk about funeral arrangements at this time."
Correct Answer: B
Rationale: The correct answer is B because an effective coping strategy involves mutual support and communication within the family. This statement reflects effective coping skills as the family is shown to be helping each other through the difficult time. Choice A is incorrect as maintaining hope does not necessarily indicate effective coping. Choice C focuses on future events and may not address the current situation of coping with a terminally ill family member. Choice D avoids discussing important aspects of end-of-life planning, which may not reflect effective coping with the situation at hand.
A healthcare professional is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The professional should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 107 mL/hr
- B. 120 mL/hr
- C. 95 mL/hr
- D. 100 mL/hr
Correct Answer: A
Rationale: To calculate the infusion rate, divide the total volume (750 mL) by the total time (7 hr). 750 · 7 ≈ 107 mL/hr. Choice A is correct because it accurately calculates the infusion rate based on the total volume and time. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate in this scenario.
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?
- A. Obtain client information
- B. Develop a plan of care
- C. Implement nursing interventions
- D. Evaluate the client's response to treatment
Correct Answer: A
Rationale: The correct answer is A: Obtain client information. The first step in the nursing process is assessment, which involves gathering data about the client's condition, needs, and preferences. This information forms the foundation for developing a comprehensive plan of care. Developing a plan of care (Choice B) comes after assessment to address the identified needs. Implementing nursing interventions (Choice C) follows the development of the plan of care. Evaluating the client's response to treatment (Choice D) occurs after implementing the interventions to determine the effectiveness of the care provided. Therefore, the initial and priority step is to obtain client information through assessment.