Nokea
A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
- A. Lie prone and let her feet hang over the mattress edge
- B. Lie supine, with her feet rotated inward
- C. Lie on her right side and point her toes downward
- D. Lie on her left side and allow her feet to remain in a neutral position
Correct Answer: A
Rationale: Lying prone with feet hanging over the mattress edge promotes knee extension, helping to prevent or reduce flexion contractures in rheumatoid arthritis.
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The client presents to the emergency room with a hyphema. Which action by the nurse would be best?
- A. Elevate the head of the bed and apply ice to the eye
- B. Place the client in a supine position and apply heat to the knee
- C. Insert a Foley catheter and measure the intake and output
- D. Perform a vaginal exam and check for a discharge
Correct Answer: A
Rationale: Elevating the head and applying ice reduces intraocular pressure and swelling in hyphema, a bleed in the eye.
A critically injured woman is rushed to the ER. She needs an immediate blood transfusion, and there is no time to crossmatch blood type. The nurse anticipates the physician will call for
- A. 1 unit of AB positive blood.
- B. 1 unit of O positive blood.
- C. 1 unit of AB negative blood.
- D. 1 unit of O negative blood.
Correct Answer: D
Rationale: O negative blood is the universal donor, safe for emergency transfusions without crossmatching, minimizing reaction risk.
The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is:
- A. Fluid volume deficit
- B. Alteration in body image
- C. Impaired oxygen exchange
- D. Alteration in elimination
Correct Answer: A
Rationale: Fluid volume deficit is the priority due to the risk of dehydration from high ileostomy output, which can lead to electrolyte imbalances and other complications.
A nurse is working in a residential facility when a fire breaks out in one hallway. The nurse and an elderly client are trapped in the client's room and cannot get out. The nurse should
- A. crawl in the closet with the client and shut the door.
- B. open a window in the client's room.
- C. instruct the client to crawl under the bed.
- D. leave the door to the room open.
Correct Answer: B
Rationale: Opening a window provides ventilation and a potential escape route while avoiding smoke inhalation. Keeping the door closed prevents smoke entry, and crawling under the bed or in a closet is unsafe.
The nurse is reviewing medications with a client who is to be scheduled for outpatient rotator cuff repair. Which of the following medications does the nurse anticipate the client will be advised to avoid on the morning of the surgery?
- A. Metoprolol.
- B. Synthroid.
- C. Aspirin.
- D. Prozac.
Correct Answer: C
Rationale: Aspirin (C) is typically avoided before surgery due to its antiplatelet effects, which increase bleeding risk. Metoprolol (A), Synthroid (B), and Prozac (D) are generally continued unless otherwise directed.