Nokea
A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
- A. Each movement is repeated 5 times by the patient.
- B. Each movement is performed until the patient experiences pain.
- C. Each movement is completed quickly and smoothly by the nurse.
- D. Each movement is moved just to the point of resistance by the nurse.
Correct Answer: D
Rationale: The correct answer is D because moving each joint just to the point of resistance during passive ROM exercises helps prevent injury and avoids causing pain to the patient. Moving beyond the point of resistance can result in muscle strain or joint damage. This technique allows the nurse to safely improve joint mobility without causing harm.
Choice A is incorrect because the patient may not be able to repeat the movement 5 times due to their impaired mobility. Choice B is incorrect because continuing movement until the patient experiences pain is harmful and can lead to injury. Choice C is incorrect because moving quickly and smoothly may not allow the nurse to gauge the patient's tolerance and could potentially cause harm.
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Nurse observes smoke coming from under the door of the staff lounge. What is the priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The correct answer is C: Evacuate the clients. This is the priority action because ensuring the safety of the clients is the nurse's primary responsibility. Evacuating the clients from the area of potential danger is crucial to prevent harm. A: Extinguishing the fire should be left to trained personnel. B: Pulling the fire alarm is important, but evacuating clients takes precedence. D: Closing doors may help contain the fire but doesn't ensure immediate safety.
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: The correct interventions for the nurse to include are A, B, C, and E. A is correct because helping the client see the benefits of their actions can motivate them to engage in health promotion activities. B is important to identify the client's support systems to provide a strong network for the client. C is crucial to suggest and recommend community resources that can further support the client in maintaining cardiovascular health. E is necessary to teach stress management strategies as stress can impact cardiovascular health. Choices D, F, and G are incorrect because setting goals for the client without their input may not be effective, and leaving options blank does not contribute to the client's care plan.
Nurse is preparing discharge summary for client whose had knee surgery & is going home. Which following info about client should nurse include in it?
- A. Advance directives status
- B. Where to go for follow-up care
- C. Instructions for diet/meds
- D. Most recent vital sign data
- E. Contact info for home healthcare agency
- F. Follow-up care
- G. medication
Correct Answer: B,C,E
Rationale: The correct answer includes where to go for follow-up care, instructions for diet/meds, and contact info for home healthcare agency. Follow-up care ensures continuity of care post-surgery. Instructions for diet/meds are crucial for recovery. Contact info for home healthcare agency facilitates additional support at home. Advance directives status is important but not directly related to post-surgery care. Most recent vital sign data is essential for monitoring during hospitalization, not for discharge summary. Just mentioning follow-up care or medication without specific details is not as comprehensive as providing detailed instructions and contact information.
Nurse reviewing nutrition guidelines with parents of 11 yo. Which parent statement should indicate to nurse that they understand guidelines for school-age children?
- A. She wants to eat as much as us, but we're afraid she'll be overweight.
- B. She skips lunch sometimes but we figure it's okay as long as she has healthy breakfast & dinner.
- C. We limit fast food restaurant meals to 3x/week now
- D. We reward her school achievements with point system instead of pizza or ice cream
Correct Answer: D
Rationale: The correct answer is D because it demonstrates understanding of the guidelines by promoting non-food rewards for school achievements, which helps instill healthy habits and a positive relationship with food. This approach encourages the child to associate success with non-food rewards, fostering a healthy attitude towards food and eating habits. Choices A, B, and C focus on the child's weight, meal skipping, and fast food consumption, which are not aligned with the guidelines for school-age children. These choices may promote unhealthy eating behaviors or weight concerns.
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face
- D. neck
- E. chest
Correct Answer: C
Rationale: The correct answer is C: Client with partial & full-thickness burns to face. This client is the highest priority due to airway compromise risk from facial burns. Airway is a top priority in mass casualty events to prevent respiratory distress or failure. Crush injuries (A) may be severe but not immediately life-threatening. Laceration (B) to head can be managed with proper wound care. Clients with neck (D) or chest (E) injuries may have potential serious complications, but airway takes precedence in this scenario.