Nokea
A client with a fractured hip asks the nurse about activity after discharge. The nurse should explain to the client that she should refrain from which of the following activities?
- A. Crossing her legs at the knee
- B. Sitting in a recliner
- C. Walking up stairs
- D. Carrying objects that weigh more than 10 pounds
Correct Answer: A
Rationale: Crossing legs at the knee can cause hip adduction, risking dislocation in a fractured hip. Other activities are generally safe with proper precautions.
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The nurse is reinforcing education about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply.
- A. Chest physiotherapy is administered only if respiratory symptoms worsen.
- B. I will give my child pancreatic enzymes with all meals and snacks.
- C. I will increase my child's salt intake during hot weather.
- D. Our child will need a high-carbohydrate, high-protein diet.
- E. We will limit our child's participation in sports activities.
Correct Answer: B,C,D
Rationale: Pancreatic enzymes with meals (B), increased salt in hot weather (C), and a high-calorie, high-protein diet (D) are correct for cystic fibrosis management. Chest physiotherapy (A) is routine, not symptom-based, and limiting sports (E) is unnecessary unless advised.
The nurse has attended a staff education program about administering intramuscular injections. Which of the following statements by the nurse would indicate a correct understanding of the program?
- A. I will insert the needle at a 45-degree angle.
- B. I will wait 3 seconds after injecting the medication before removing the needle.
- C. I will gently massage the injection site after removing the needle.
- D. I will use my hand to displace subcutaneous tissue prior to inserting the needle.
Correct Answer: D
Rationale: Displacing subcutaneous tissue (D) via the Z-track method prevents leakage and irritation. IM injections use a 90-degree angle (A is incorrect), waiting 3 seconds (B) is not standard, and massaging (C) is avoided for some medications.
The nurse is reinforcing teaching to the parent of a child recently diagnosed with attention deficit hyperactivity disorder, combined type. Which statement by the parent requires intervention?
- A. I should offer only two options when my child is choosing things like clothes or meals.
- B. I will need to advocate for an individualized educational plan for my child.
- C. My child will most likely outgrow this disorder in early adulthood, around age 20.
- D. When talking with my child, I should focus and not be multi-tasking.
Correct Answer: C
Rationale: ADHD often persists into adulthood, so stating it will be outgrown by age 20 (C) is incorrect and requires intervention. Limiting choices (A), advocating for an IEP (B), and focusing during conversations (D) are appropriate.
The nurse is caring for a client with a tracheostomy who has an order to begin oral intake. Which of the following actions should the nurse take to decrease the client's risk for aspiration?
- A. Fully inflate the tracheostomy cuff before the client begins to eat.
- B. Encourage the client to use a straw when drinking fluids.
- C. Instruct the client to tilt the head back when swallowing
- D. Provide thickened liquids for the client.
Correct Answer: D
Rationale: Thickened liquids (D) reduce aspiration risk by slowing transit. Inflating the cuff (A) is not always necessary, straws (B) may increase risk, and tilting the head back (C) worsens aspiration.
The nursing assistant is caring for an adult who has a fractured femur and is in Buck's extension traction awaiting surgery. The nurse is observing the nursing assistant administer morning care. Which action by the nursing assistant needs correction?
- A. The nursing assistant leaves the weights in place while bathing the client.
- B. The nursing assistant turns the client's head to the side while administering oral hygiene.
- C. The nursing assistant makes the bed from head to foot.
- D. The nursing assistant turns the client on the side for back care.
Correct Answer: D
Rationale: Turning the client on the side disrupts Buck's traction alignment, which requires constant pull. Weights should stay in place, head turning is safe, and bed-making direction is irrelevant.