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A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?
- A. Encourage the client to use the overbed trapeze.
- B. Maintain abduction of the client's residual limb with a pillow.
- C. Caution the client to avoid a prone position while in bed.
- D. Keep a loose, absorbent dressing over the client's surgical site.
Correct Answer: A
Rationale: Using the trapeze builds upper body strength for mobility.
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The client is taking multiple medications and asks about possible interactions.
A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?
- A. Social worker
- B. Advanced practice nurse
- C. Patient care technician
- D. Psychologist
Correct Answer: B
Rationale: An advanced practice nurse can expertly assess medication interactions.
A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?
- A. Moves objects to mouth
- B. Anterior fontanel closed
- C. Rolls from back to abdomen
- D. Posterior fontanel closed
Correct Answer: B
Rationale: Anterior fontanel closure before 12-18 months may indicate abnormal development.
The client is experiencing delirium.
A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?
- A. Echopraxia
- B. Aphasia
- C. Acute onset of confusion
- D. Inability to read
Correct Answer: C
Rationale: Acute onset of confusion is a hallmark of delirium.
A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?
- A. Believes the death is punishment for bad behavior
- B. Understands that everyone dies eventually
- C. Recognizes the parent will never wake up
- D. Expresses curiosity about the funeral service
Correct Answer: A
Rationale: Preschoolers often view death as punishment due to magical thinking.
The client has methicillin-resistant Staphylococcus aureus (MRSA).
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?
- A. Don gloves prior to assisting the client with brushing their teeth.
- B. Have the client wear a mask when they are out of their room.
- C. Ensure that the negative air pressure is active for the client's room.
- D. Place the client in a room with a high-efficiency particulate air (HEPA) filter.
Correct Answer: A
Rationale: Gloves prevent MRSA transmission during close contact like brushing teeth.