Nokea
A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action?
- A. Prevention of atelectasis
- B. Prevention of renal calculi
- C. Prevention of pressure ulcers
- D. Prevention of joint contractures
Correct Answer: D
Rationale: The correct answer is D, prevention of joint contractures. Passive ROM and splinting help maintain joint flexibility and prevent contractures in immobile patients. Contractures are abnormal shortening of muscles causing joints to remain in fixed positions. Preventing joint contractures is essential for preserving mobility.
A: Prevention of atelectasis is unrelated to passive ROM and splinting.
B: Prevention of renal calculi is not a direct outcome of passive ROM and splinting.
C: Prevention of pressure ulcers is important but not directly related to joint mobility.
In summary, the goal of the nurse's action is to prevent joint contractures, as immobility can lead to loss of joint motion.
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An RN is making assignments for client care to an LPN at the beginning of shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24h post-op to use incentive spirometer
- B. Collecting clean-catch urine specimen
- C. Providing nasopharyngeal suctioning for pneumonia client
- D. Replacing cartridge & tubing on PCA pump
Correct Answer: D
Rationale: The LPN should question replacing cartridge & tubing on PCA pump (Choice D) because this task involves manipulating the patient's medication delivery system, which is beyond the LPN's scope of practice. LPNs are not trained to handle complex medication administration devices like PCA pumps, as this requires a higher level of knowledge and skill typically reserved for RNs. The LPN should advocate for clarification from the RN or delegate this task to someone with the appropriate training. Choices A, B, and C are within the LPN's scope of practice and do not require specialized training like manipulating a PCA pump.
Nurse is reviewing nutrition guidelines with parents of 2 yo. Which parent statement should indicate to nurse that they understand feeding guidelines for this age group?
- A. I should keep feeding my son whole milk until he's 3 yo
- B. It's okay for me to give him a cup of apple juice with each meal
- C. I'll give my son about 2 tablespoons of each food at mealtimes
- D. My son loves popcorn, & I know it's better for him than sweets
Correct Answer: C
Rationale: Correct Answer: C
Rationale: Giving a 2-year-old about 2 tablespoons of each food at mealtimes aligns with appropriate portion sizes for toddlers. This indicates an understanding of feeding guidelines for this age group, promoting balanced nutrition and preventing overfeeding.
Incorrect Answers:
A: Keeping a child on whole milk until 3 yo is not recommended due to the risk of excess fat intake.
B: Offering a cup of apple juice with each meal can lead to excessive sugar intake and may displace more nutritious foods.
D: Popcorn, while a better choice than sweets, may still pose a choking hazard for young children and may not provide balanced nutrition.
A nursing instructor is reviewing steps of the nursing process with students. Which of the following data are objective?
- A. Respiratory rate 22/min
- B. I can only walk 3 blocks before pain starts
- C. Pain level 3/10
- D. Skin pink warm
- E. Urine output 300mL/8hr
- F. Dressing clean dry intact
Correct Answer: A,D,E,F
Rationale: The correct answers are A, D, E, and F. Objective data are measurable and observable.
A: Respiratory rate 22/min is measurable.
D: Skin pink warm is observable.
E: Urine output 300mL/8hr is measurable.
F: Dressing clean dry intact is observable.
Choices B and C are subjective as they are based on the patient's perception and cannot be measured or observed directly. Choice G is incomplete.
Nurse providing pre-op teaching for client scheduled for mastectomy next day. Which client statement indicates client is ready to learn?
- A. I don't want my spouse to see my incision
- B. Will you be able to give me pain meds after surgery?
- C. Can you tell me about how long the surgery will take?
- D. My roommate listens to everything I say
Correct Answer: C
Rationale: The correct answer is C because the client is showing readiness to learn by asking a relevant question about the surgery process. This indicates an active interest in understanding what will happen during the procedure, which is crucial for preparing mentally and emotionally. Choice A is more focused on personal discomfort, not readiness to learn. Choice B is about pain management, not understanding the surgical process. Choice D is unrelated to the situation.
A nurse is assessing body alignment. What is the nurse monitoring?
- A. The relationship of one body part to another while in different positions
- B. The coordinated efforts of the musculoskeletal and nervous systems
- C. The force that occurs in a direction to oppose movement
- D. The inability to move about freely
Correct Answer: A
Rationale: The correct answer is A. The nurse is monitoring the relationship of one body part to another while in different positions to ensure proper alignment. This is crucial for preventing musculoskeletal issues. Choice B refers to coordination, not body alignment. Choice C refers to resistance, not alignment. Choice D refers to immobility, not alignment.