Nokea
A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?
- A. Remain on bed rest for 24 hours following the procedure.
- B. Participate in range-of-motion exercises.
- C. Use an incentive spirometer every 4 hours.
- D. Place a pillow under your knees while in bed.
Correct Answer: B
Rationale: The correct answer is B: Participate in range-of-motion exercises. Range-of-motion exercises help prevent immobility-related complications such as blood clots and promote circulation postoperatively. This helps prevent complications like deep vein thrombosis. Choices A, C, and D are incorrect. Remaining on bed rest for 24 hours can increase the risk of blood clots. Using an incentive spirometer every 4 hours helps with lung function, not circulation. Placing a pillow under the knees only helps with comfort, not circulation.
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A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
- A. Check the client for injuries.
- B. Move hazardous objects away from the client.
- C. Notify the provider.
- D. Ask the client to describe how she felt prior to the fall.
Correct Answer: A
Rationale: The correct answer is A: Check the client for injuries. This should be the first action taken because the nurse needs to assess the client's immediate physical condition to determine if there are any life-threatening injuries that require immediate attention. Moving hazardous objects (B) can wait until after ensuring the client's safety. Notifying the provider (C) can also be done after assessing the client's condition. Asking the client about how she felt prior to the fall (D) is important but not as urgent as checking for injuries.
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?
- A. Suggest rinsing his mouth with an alcohol-based mouthwash
- B. Provide humidification of the room air
- C. Offer the client saltine crackers between meals
- D. Instruct the client on the use of esophageal speech
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Xerostomia is dry mouth often caused by radiation therapy, which can lead to discomfort and difficulty swallowing. Humidifying the room air can help alleviate dryness, making it easier for the client to breathe and swallow. Alcohol-based mouthwash (A) can worsen dryness due to its drying effect. Saltine crackers (C) can be difficult to swallow with a dry mouth. Esophageal speech (D) is not relevant to xerostomia.
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place a container for soiled linens inside the client's room. This intervention is important to prevent the spread of infection. Placing a container for soiled linens inside the client's room ensures that contaminated linens are contained and not mixed with other linens, reducing the risk of transmitting the infection to others.
Rationale for why other choices are incorrect:
A: Wearing an N95 mask is not necessary unless the client has airborne precautions, such as tuberculosis.
C: Placing the client in a negative airflow room is typically reserved for clients with airborne infections to prevent the spread of droplet nuclei in the air.
D: Removing the mask after exiting the client's room is incorrect as the mask should be removed before exiting to prevent contamination outside the room.
In summary, choice B is correct as it directly addresses infection control measures related to soiled linens, while the other choices are not relevant to isolation precautions or are incorrect based on standard
A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds.
- C. Place the client in a high-Fowler's position.
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate because it helps create a peaceful appearance for the deceased client, providing a more dignified and comforting view for the family during the viewing. Holding the eyes shut is a common practice to maintain a natural appearance and show respect for the deceased.
Crossing the client's arms (Choice A) is not necessary and may not be culturally appropriate for all families. Placing the client in a high-Fowler's position (Choice C) is not recommended as it may not be comfortable or appropriate for viewing. Removing the client's dentures (Choice D) is also unnecessary and may not be respectful to the deceased.
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?
- A. Initiate a requisition for a replacement CPM device.
- B. Report the defect to the equipment maintenance staff.
- C. Remove the device from the room.
- D. Ensure the device inspection sticker is current.
Correct Answer: C
Rationale: The correct action the nurse should take first is to remove the device from the room (Choice C). This is crucial because a frayed electrical cord poses a significant safety risk, potentially leading to electric shock or fire hazard. By removing the device from the room, the nurse ensures that the client and others are not exposed to the danger posed by the damaged cord. Initiating a requisition for a replacement device (Choice A) can be done after ensuring immediate safety. Reporting the defect to equipment maintenance staff (Choice B) is important, but it is secondary to removing the device from the room. Ensuring the device inspection sticker is current (Choice D) is not the priority when there is a clear safety issue present.