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A nurse delegating ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. The roommate is up independently
- B. Client ambulates with slippers over antiembolic stockings
- C. Client uses front-wheeled walker when ambulating
- D. Client had pain medication 30 min ago
- E. Client is allergic to codeine
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. The nurse should share that the client ambulates with slippers over antiembolic stockings (B) to ensure proper footwear and prevent falls. Sharing that the client uses a front-wheeled walker when ambulating (C) is vital for safety and stability. Informing the AP that the client had pain medication 30 minutes ago (D) is crucial to prevent overexertion and ensure appropriate monitoring for side effects. Choice A is incorrect because the roommate's independence is not relevant to the client's ambulation. Choice E is also incorrect as the client's allergy to codeine is not directly related to ambulation delegation.
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A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action?
- A. Prevention of atelectasis
- B. Prevention of renal calculi
- C. Prevention of pressure ulcers
- D. Prevention of joint contractures
Correct Answer: D
Rationale: The correct answer is D, prevention of joint contractures. Passive ROM and splinting help maintain joint flexibility and prevent contractures in immobile patients. Contractures are abnormal shortening of muscles causing joints to remain in fixed positions. Preventing joint contractures is essential for preserving mobility.
A: Prevention of atelectasis is unrelated to passive ROM and splinting.
B: Prevention of renal calculi is not a direct outcome of passive ROM and splinting.
C: Prevention of pressure ulcers is important but not directly related to joint mobility.
In summary, the goal of the nurse's action is to prevent joint contractures, as immobility can lead to loss of joint motion.
Nurse reviewing CDC's immunization recommendations for young adult. Which should nurse include in this discussion? (Select all that apply.)
- A. HPV
- B. Measles, mumps, rubella
- C. Varicella
- D. Haemophilus influenzae type b
- E. Polio
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. The nurse should include HPV, measles, mumps, rubella, and varicella in the discussion as these are recommended immunizations for young adults by the CDC. HPV vaccination helps prevent certain types of cancers and genital warts. Measles, mumps, and rubella vaccines protect against highly contagious diseases. Varicella vaccine prevents chickenpox. Choices D, E, F, and G are incorrect. Haemophilus influenzae type b and polio vaccines are typically given during infancy and childhood, not young adulthood. The options F and G are incomplete.
A nurse receives a prescription for an antibiotic for a client with cellulitis. Upon review
- A. the nurse finds the client is allergic and calls the provider. Which attitude does the nurse demonstrate?
- B. Fairness
- C. Responsibility
- D. Risk taking
- E. Creativity
Correct Answer: B
Rationale: The correct answer is B: Fairness. The nurse demonstrates fairness by acknowledging the client's allergy and taking the necessary steps to address it, ensuring the client's safety and well-being. Responsibility (C) could also be a consideration, but fairness is more directly related to this specific scenario. Risk taking (D) and Creativity (E) are not relevant in this situation as the nurse's actions are based on standard protocols and patient safety.
A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
- A. Each movement is repeated 5 times by the patient.
- B. Each movement is performed until the patient experiences pain.
- C. Each movement is completed quickly and smoothly by the nurse.
- D. Each movement is moved just to the point of resistance by the nurse.
Correct Answer: D
Rationale: The correct answer is D because moving each joint just to the point of resistance during passive ROM exercises helps prevent injury and avoids causing pain to the patient. Moving beyond the point of resistance can result in muscle strain or joint damage. This technique allows the nurse to safely improve joint mobility without causing harm.
Choice A is incorrect because the patient may not be able to repeat the movement 5 times due to their impaired mobility. Choice B is incorrect because continuing movement until the patient experiences pain is harmful and can lead to injury. Choice C is incorrect because moving quickly and smoothly may not allow the nurse to gauge the patient's tolerance and could potentially cause harm.
Nurse providing pre-op teaching for client scheduled for mastectomy next day. Which client statement indicates client is ready to learn?
- A. I don't want my spouse to see my incision
- B. Will you be able to give me pain meds after surgery?
- C. Can you tell me about how long the surgery will take?
- D. My roommate listens to everything I say
Correct Answer: C
Rationale: The correct answer is C because the client is showing readiness to learn by asking a relevant question about the surgery process. This indicates an active interest in understanding what will happen during the procedure, which is crucial for preparing mentally and emotionally. Choice A is more focused on personal discomfort, not readiness to learn. Choice B is about pain management, not understanding the surgical process. Choice D is unrelated to the situation.