Nokea
A nurse is caring for a client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
- A. Cross the client's legs at the knees
- B. Maintain the client's legs in a neutral position
- C. Avoid placing a pillow under the client's knees
- D. Elevate the client's legs
Correct Answer: C
Rationale: The correct action to prevent dislocation of the prosthesis after hip replacement surgery is to avoid placing a pillow under the client's knees. Placing a pillow can cause hip adduction, leading to dislocation. Crossing the client's legs at the knees and elevating the client's legs can also increase the risk of hip dislocation. Maintaining the client's legs in a neutral position is important to prevent complications.
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What are the key nursing interventions for a patient undergoing dialysis?
- A. Monitor fluid balance and administer heparin
- B. Monitor blood pressure and prevent clot formation
- C. Administer medications and monitor blood chemistry
- D. Provide dietary education and encourage protein intake
Correct Answer: A
Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.
What are common risk factors for urinary tract infections (UTIs)?
- A. Poor hygiene and dehydration
- B. Increased sexual activity and pregnancy
- C. Use of urinary catheters and prolonged bed rest
- D. Family history and obesity
Correct Answer: A
Rationale: The correct answer is A: Poor hygiene and dehydration are common risk factors for urinary tract infections (UTIs). While choices B, C, and D may play a role in certain cases, poor hygiene and dehydration are more universally recognized as key factors contributing to UTIs. Increased sexual activity and pregnancy (choice B) can also increase the risk of UTIs, but they are not as universal as poor hygiene and dehydration. Choices C and D, the use of urinary catheters and prolonged bed rest, and family history and obesity, respectively, are risk factors for UTIs but are not as commonly associated as poor hygiene and dehydration.
A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure?
- A. Nausea
- B. Confusion about own name
- C. Rapid pulse
- D. Vomiting
Correct Answer: B
Rationale: Confusion, especially about one's own name, is a sign of increased intracranial pressure and should be addressed. Nausea and vomiting are common symptoms of increased intracranial pressure, but confusion about personal information is a more specific and critical indication that requires immediate attention. Rapid pulse may be a possible response to increased intracranial pressure, but it is not as specific as confusion about own name in this scenario.
A nurse is caring for a client with an NG tube who reports nausea and a decrease in gastric secretions. What is the nurse's next step?
- A. Administer an antiemetic
- B. Irrigate the NG tube with sterile water
- C. Increase the suction setting
- D. Replace the NG tube
Correct Answer: B
Rationale: The correct next step for the nurse is to irrigate the NG tube with sterile water. This action helps relieve blockages that may be causing the symptoms of nausea and decreased gastric secretions. Administering an antiemetic (Choice A) may mask the underlying issue without addressing the possible blockage. Increasing the suction setting (Choice C) is not indicated without first addressing the potential blockage. Replacing the NG tube (Choice D) is also premature before attempting to clear any obstructions.
What is the proper technique for measuring a patient's blood pressure?
- A. Place the cuff at heart level and listen for Korotkoff sounds
- B. Ensure the patient is in a seated position and inflate the cuff to 180 mmHg
- C. Use a manual sphygmomanometer and measure blood pressure on both arms
- D. Monitor pulse rate and apply pressure to the brachial artery
Correct Answer: A
Rationale: The correct technique for measuring blood pressure involves placing the cuff at heart level to ensure accurate readings. Listening for Korotkoff sounds helps determine the systolic and diastolic pressures. Choice B is incorrect as inflating the cuff to 180 mmHg is excessive and can lead to inaccurate readings. Choice C is incorrect as it is unnecessary to measure blood pressure on both arms unless there is a specific medical reason to do so. Choice D is incorrect as monitoring pulse rate and applying pressure to the brachial artery are not part of the standard blood pressure measurement technique.