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A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?
- A. Measure from the client's heel to the gluteal fold.
- B. Measure the length of the client's feet.
- C. Measure from the client's heel to the popliteal space.
- D. Measure the client's ankle circumference.
Correct Answer: C
Rationale: The correct answer is C: Measure from the client's heel to the popliteal space. This is the correct action because knee-high antiembolic stockings should cover the area from the heel to just below the knee at the popliteal space. This measurement ensures proper sizing and compression effectiveness.
A: Measuring from the heel to the gluteal fold is incorrect as it would result in stockings that are too long and may impede circulation.
B: Measuring the length of the client's feet is irrelevant for determining the correct size of knee-high stockings.
D: Measuring the client's ankle circumference alone is insufficient for determining the appropriate length of knee-high stockings.
In summary, choice C is correct as it ensures the stockings fit properly, while the other choices are incorrect due to inaccuracies or irrelevance in determining the appropriate size for knee-high antiembolic stockings.
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A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. As individuals age, there is a natural decline in muscle mass known as sarcopenia. This is due to a decrease in muscle fiber size and number. The nurse should include this alteration in the presentation because it is a common age-related musculoskeletal change that can lead to weakness, decreased mobility, and increased risk of falls in older adults.
Choices B, C, and D are incorrect because thickened vertebral disks, decreased chest width, and increased force of isometric contractions are not typical age-related musculoskeletal changes. Thickened vertebral disks are more associated with degenerative disc disease, decreased chest width is not a common age-related change, and increased force of isometric contractions is not a typical alteration seen in older adults.
A nurse whose left hand is dominant is preparing to perform a straight catheterization for a client who is paraplegic. Which of the following actions should the nurse take?
- A. Use the left hand to cleanse the urinary meatus.
- B. Use the right hand to insert the catheter.
- C. Stand on the client's right side.
- D. Raise the bed to a comfortable working height.
Correct Answer: D
Rationale: The correct answer is D: Raise the bed to a comfortable working height. This is important to prevent strain on the nurse's back and ensure proper ergonomics during the procedure. Standing on the client's right side (Choice C) does not directly impact the procedure. Using the left hand to cleanse the urinary meatus (Choice A) could be challenging for a left-handed nurse and may not be as efficient. Using the right hand to insert the catheter (Choice B) could also be difficult for a left-handed nurse and may affect dexterity. Therefore, raising the bed to a comfortable working height is the most appropriate action to ensure the nurse's comfort and safety while performing the catheterization.
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)
- A. Apply ice to the ankle.
- B. Encourage range-of-motion exercises of the foot.
- C. Provide the client with a light snack.
- D. Apply a compression bandage.
- E. Elevate the foot.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- Apply ice to the ankle (A): Ice helps reduce swelling and inflammation by constricting blood vessels. It is essential for reducing pain and promoting healing.
- Apply a compression bandage (D): Compression helps reduce swelling and provides support to the injured area, promoting healing and preventing further damage.
- Elevate the foot (E): Elevating the foot above the heart level helps reduce swelling and promotes circulation, aiding in the healing process.
Incorrect Choices:
- Encourage range-of-motion exercises of the foot (B): Performing range-of-motion exercises on an injured ankle may worsen the injury and cause further damage.
- Provide the client with a light snack (C): Providing a snack is not a priority in this situation and does not contribute to the client's immediate care.
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and encourages the client to share their reason for seeking medical care, providing valuable information for the nurse to assess the client's health needs. Choice B is too broad and may overwhelm the client. Choice C puts the onus on the client to initiate the discussion. Choice D focuses on emotions rather than the primary reason for the hospitalization.
A nurse is caring for a client who says, 'I'm feeling a bit nervous today.' Which of the following responses should the nurse make?
- A. Please explain what you mean by nervous.
- B. Why are you nervous?
- C. Would a backrub ease your nervousness?
- D. You look like you feel nervous.
Correct Answer: A
Rationale: Seeking clarification helps the nurse understand the client's feelings more accurately.