Nokea
A man who had a right below-the-knee amputation is placed in the prone position for one hour three times a day. The nurse explains to the man that this is done to prevent which problem?
- A. Atelectasis
- B. Thrombophlebitis
- C. Hip flexion contractures
- D. Wound infection
Correct Answer: C
Rationale: Prone positioning stretches hip flexors, preventing contractures post-amputation. It doesn't primarily address atelectasis, thrombophlebitis, or infection.
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The nurse has reinforced teaching with a client with newly diagnosed polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I should take an iron supplement daily.'
- B. I should increase my daily fluid intake.'
- C. I may require frequent phlebotomy.'
- D. I will take a low-dose aspirin daily.'
Correct Answer: A
Rationale: Iron supplements (A) can worsen polycythemia vera by increasing red blood cell production, requiring follow-up. Increased fluids (B), phlebotomy (C), and aspirin (D) are appropriate.
A client reports that someone is in the room and trying to kill him. The nurse's best response is:
- A. No one is in your room. Let's get you more medicine.'
- B. I do not see anyone, but you seem to be very frightened.'
- C. No one can hurt you here.'
- D. Just tell the person to go away.'
Correct Answer: B
Rationale: It is important to acknowledge the client's fear. The other responses deny the client's perceptions.
The nurse observes a certified nursing assistant (CNA) moving a client up in bed. Which action by the nursing assistant indicates a need for more instruction in how to move a client?
- A. Using a pull sheet
- B. Asking another nursing assistant to help
- C. Lowering the head of the bed
- D. Pulling the client by the shoulders
Correct Answer: D
Rationale: Pulling by the shoulders risks injury to the client's skin and joints. Using a pull sheet, getting help, and lowering the bed are correct techniques to ensure safety.
The practical nurse is collaborating with the registered nurse to form a care plan for a client with a possible diagnosis of Guillain-Barré syndrome. The nurse should give priority to which client assessment?
- A. Orthostatic blood pressure changes
- B. Presence or absence of knee reflexes
- C. Pupil size and reaction to light
- D. Rate and depth of respirations
Correct Answer: D
Rationale: Respiratory assessment (D) is the priority in Guillain-Barré syndrome due to the risk of respiratory muscle paralysis. Reflexes (B) are relevant but less urgent, and blood pressure (A) and pupils (C) are not primary concerns.
A 13-month-old child is admitted to the pediatric unit with diarrhea and vomiting. The mother tells the nurse that she is worried because her son does not yet walk. She says her other children walked at eight and nine months and asks what could be wrong with this child. How should the nurse respond?
- A. All babies are different. It is not abnormal that the baby is not yet walking.'
- B. The baby should be walking. I'll let the doctor know he is behind developmentally.'
- C. Your son is probably enjoying being the baby and is not eager to grow up and walk.'
- D. Walking requires complex coordination. Your son is probably just a little slow to develop this. Don't worry.'
Correct Answer: A
Rationale: Walking typically occurs between 9-18 months; at 13 months, not walking is within normal variation, reassuring the mother without dismissing concerns.