Nokea
A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?
- A. Verbal teaching in short sessions throughout the day.
- B. Pre-operative booklet on the surgery in Braille.
- C. Provide a tape for the client.
- D. Have the blind patient's family member instruct the patient.
Correct Answer: A
Rationale: Information is smaller amounts is easier to retain. Teaching the day before the procedure is best accomplished in a one on one format.
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To remove a client's gown when she has an intravenous line, the nurse should:
- A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown.
- B. cut the gown with scissors.
- C. thread the bag and tubing through the gown sleeve, keeping the line intact.
- D. temporarily disconnect the tubing from the intravenous container and thread it through the gown.
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.
The dietitian prescribes a 24-hour calorie count for the malnourished hospitalized client. Which action should be taken by the nurse?
- A. Ask the client to recall at the end of the day the food and beverages consumed.
- B. Inform the client how to count the calories in the food and beverages consumed.
- C. Inform the client that a record will be maintained of food and beverages consumed.
- D. Ask the client to identify the food groups and foods that are being consumed in each.
Correct Answer: C
Rationale: C: Recording food intake ensures accurate calorie counts. A: Recall is unreliable. B: Clients don't calculate calories in hospital. D: Food groups don't provide calorie data.
To ensure proper immobilization and increase client comfort when using a rigid splint:
- A. place the client on a stretcher before splinting
- B. place the client on a long spine board before splinting
- C. pad the spaces between the body part and the splint
- D. ensure that the splint conforms to the body curves
Correct Answer: C
Rationale: Padding spaces in a rigid splint prevents pressure points, enhancing comfort and ensuring effective immobilization.
The client uses a walker to ambulate with partial weight-bearing after foot surgery. What should the nurse observe when this client is using the walker correctly?
- A. Has elbows bent at a 30-degree angle
- B. Is bent over the front bar of the walker
- C. While walking, lifts the walker 2 inches
- D. Has a walker that has four wheels in place
Correct Answer: A
Rationale: A: Elbows at 30 degrees indicate proper walker height. B: Bending over risks poor posture and falls. C: Lifting the walker prevents partial weight-bearing. D: Four-wheeled walkers are unsuitable for partial weight-bearing.
The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
- A. The LPN elevates the head of the bed at least 30 degrees.
- B. If the residual is greater than 200 mL, the LPN should not administer the enteral feeding.
- C. The residual should be discarded prior to administering the tube feeding.
- D. The residual pH level is tested to ensure appropriate placement.
Correct Answer: C
Rationale: The residual should be injected back into the PEG tube, as it contains important enzymes and nutrients.