Nokea
A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important?
- A. Administering pain medication before transport
- B. Answering any last-minute questions by the client
- C. Ensuring the family has directions to the facility
- D. Providing a verbal hand-off report to the facility
Correct Answer: D
Rationale: As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority.
You may also like to solve these questions
A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement?
- A. I always wear long sleeves, pants, and a hat when outdoors
- B. I try not to use concentrate that contains any type of sunblock
- C. Since I tend to sweat a lot, I use a lot of baby powder
- D. Since I can be exposed to the sun, I have been using a tanning bed
Correct Answer: A
Rationale: Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, and avoiding drying agents such as powder and tanning beds.
A nurse is caring for a client with systemic sclerosis. The client's facial skin is very tight, limiting the ability to open the mouth. Besides a consultation with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate?
- A. Dentist
- B. Massage therapist
- C. Occupational therapy
- D. Physical therapy
Correct Answer: A
Rationale: With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.
A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection?
- A. Assess the client's white blood cell count
- B. Inspect the client's white blood cell count
- C. Monitor the client's temperature every 4 hours
- D. Use aseptic technique for dressing changes
Correct Answer: D
Rationale: Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to prevent wound infection. Other actions do not prevent infection but can lead to early detection of an infection that is already present.
A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic reporting sedation. What response by the nurse is most appropriate?
- A. A little sedation will help you get some rest
- B. Depression often accompanies fibromyalgia
- C. Duloxetine reduces pain by increasing serotonin and norepinephrine
- D. You will have more energy after taking this drug
Correct Answer: C
Rationale: Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.
A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed?
- A. Assess the distal circulation in 30 minutes
- B. Change the settings based on a range of motion
- C. Raise the lower siderail on the affected side
- D. Remind the client to do quad-setting exercises
Correct Answer: C
Rationale: Because the client's leg is strapped into the CPM, if it falls off the bed due to movement, the client's leg (and knee) could be injured. Raising the siderail prevents this. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjust the CPM settings. Quad-setting exercises are not related to the CPM machine.