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A nurse is instructing a postop client about the sequential compression device the provider has prescribed. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. This device will keep me from getting sores on my skin.
- B. This thing will keep the blood pumping through my leg.
- C. With this thing on, my leg muscles won't get weak.
- D. This device is going to keep my joints in good shape.
Correct Answer: B
Rationale: The correct answer is B: "This thing will keep the blood pumping through my leg." This statement shows understanding because sequential compression devices help prevent blood clots by promoting blood circulation in the legs. Option A is incorrect as the device does not prevent skin sores. Option C is incorrect as it doesn't specifically address blood circulation. Option D is incorrect as the device does not impact joint health.
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A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all.
- A. Fever
- B. Malaise
- C. Edema
- D. Pain or tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A, B, E
Rationale: The correct answer is A, B, E. Fever is a common systemic response to infection as the body raises its temperature to help fight off pathogens. Malaise, a general feeling of discomfort or uneasiness, is also a systemic manifestation indicating a more widespread infection affecting overall well-being. An increase in pulse and respiratory rate can indicate systemic involvement as the body tries to cope with the infection. Edema, pain, or tenderness are more indicative of localized infections and not typically seen in systemic infections.
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. What is the nurse's highest assessment priority before performing this procedure?
- A. Check how long the feeding container has been opened.
- B. Verify the placement of the NG tube.
- C. Confirm that the client doesn't have diarrhea.
- D. Make sure the client is alert & oriented.
Correct Answer: B
Rationale: The correct answer is B: Verify the placement of the NG tube. This is the highest assessment priority before instilling enteral feeding to prevent complications like aspiration. The nurse must ensure the NG tube is correctly positioned in the stomach to avoid feeding into the lungs. Checking the length of time the feeding container has been open (A) is important but not as critical as verifying tube placement. Confirming the client doesn't have diarrhea (C) is important for monitoring overall health but not directly related to the procedure. Ensuring the client is alert and oriented (D) is essential but not the priority for this specific procedure.
A nurse is caring for a client who is receiving continuous enteral feedings. What is the highest priority intervention when the nurse suspects aspiration?
- A. Auscultate breath sounds.
- B. Stop the feeding.
- C. Obtain a chest x-ray.
- D. Initiate oxygen therapy.
Correct Answer: B
Rationale: The correct answer is B: Stop the feeding. Aspiration can lead to serious complications such as pneumonia. Stopping the feeding immediately is crucial to prevent further aspiration and minimize harm to the client. Auscultating breath sounds (choice A) is important but should be done after stopping the feeding. Obtaining a chest x-ray (choice C) may be necessary later for further evaluation but is not the highest priority in this situation. Initiating oxygen therapy (choice D) may be needed depending on the client's condition, but it is not the highest priority when aspiration is suspected.
A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect?
- A. Mopping her floors
- B. Brushing the back of her hair
- C. Fastening her bra behind her back
- D. Reaching into a cabinet above her sink
Correct Answer: C
Rationale: The correct answer is C. Fastening her bra behind her back. Internal rotation of the shoulder is necessary for this activity as it involves reaching the arm behind the body. Mopping the floors (A) and brushing the back of her hair (B) primarily require shoulder abduction and flexion. Reaching into a cabinet above the sink (D) involves shoulder flexion and abduction, not internal rotation.
A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client. Which of the following information should the nurse include in her counseling?
- A. Carbon monoxide has a distinct odor
- B. Water heaters should be inspected every 5 years
- C. The lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds w/hemoglobin in the body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is crucial information because carbon monoxide binds to hemoglobin more strongly than oxygen, leading to oxygen deprivation in the body's tissues. This can result in serious health consequences, including brain damage and even death.
Explanation for why the other choices are incorrect:
A: Carbon monoxide is odorless, so it does not have a distinct odor.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body's ability to transport oxygen, rather than directly damaging the lungs.
E, F, G: No additional choices provided.