Nokea
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
- A. Palms rest lightly on the handles
- B. Elbows are flexed 0°
- C. Client walks to the front of the walker
- D. Client carries the walker
Correct Answer: A
Rationale: Palms resting lightly on the handles ensures proper weight distribution and stability.
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A nurse has delegated care of a client in wrist restraints to a nursing assistant. The nursing assistant should check the skin circulation under the restraints at least
- A. every 15 minutes.
- B. every 30 minutes.
- C. every hour.
- D. every 2 hours.
Correct Answer: C
Rationale: Restraints require circulation checks every 1-2 hours to prevent skin breakdown or neurovascular injury. Hourly checks (C) balance safety and practicality.
Which of the following are controlled substances (Schedules I through V) regulated by the Drug Enforcement Agency (DEA)? Select all that apply.
- A. Codeine
- B. Ibuprofen
- C. Diphenhydramine (Benadryl®)
- D. Hydrocodone
Correct Answer: A,D
Rationale: Codeine (A) and hydrocodone (D) are DEA-controlled substances (Schedules II-V). Ibuprofen (B) and diphenhydramine (C) are not controlled.
The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to:
- A. Place a gauze pad over the stoma
- B. Lie on her side while evacuating the pouch
- C. Bear down with each voiding
- D. Wear a well-fitting drainage bag
Correct Answer: D
Rationale: A well-fitting drainage bag is essential for managing an orthotopic bladder replacement.
A 4-year-old is scheduled for a routine tonsillectomy. Which of the following lab findings should be reported to the doctor?
- A. A hemoglobin of 12 Gm
- B. A platelet count of 200,000
- C. A white blood cell count of 16,000
- D. A urine specific gravity of 1.010
Correct Answer: C
Rationale: A white blood cell count of 16,000 suggests infection or inflammation, which should be reported before surgery.
Which vitamin should be administered with INH (isoniazid) in order to prevent possible nervous system side effects?
- A. Thiamine
- B. Niacin
- C. Pyridoxine
- D. Riboflavin
Correct Answer: C
Rationale: Pyridoxine (vitamin B6) is given with isoniazid to prevent peripheral neuropathy, a potential side effect of the medication.