Nokea
A nurse is reinforcing teaching with a client about crutch walking using the swing-through gait. Which of the following statements should the nurse include?
- A. Look down at your feet before moving the crutches.
- B. Place one crutch forward with the opposite foot and then place the second crutch forward with the other foot.
- C. Move both crutches forward, then lift and move your body past the crutches.
- D. Bear your weight against the underarm crutch pads.
Correct Answer: C
Rationale: The correct answer is C: Move both crutches forward, then lift and move your body past the crutches. This statement correctly describes the swing-through gait technique where both crutches are moved forward simultaneously followed by the client lifting and moving their body past the crutches. This technique helps maintain balance and stability during crutch walking. Looking down at your feet before moving the crutches (Choice A) is incorrect as it can cause the client to lose their balance. Placing one crutch forward with the opposite foot and then the second crutch forward with the other foot (Choice B) is the incorrect description of the swing-to gait technique. Bearing weight against the underarm crutch pads (Choice D) is incorrect as it can cause discomfort and potential nerve damage.
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A nurse is reinforcing teaching with an older adult client. Which of the following strategies should the nurse use?
- A. Incorporate teaching needs into one daily session.
- B. Emphasize visual and auditory teaching techniques.
- C. Minimize distractions by closing the door to the room.
- D. Begin with the most difficult learning tasks.
Correct Answer: B
Rationale: The correct answer is B: Emphasize visual and auditory teaching techniques. Older adults may have sensory impairments, so utilizing visual and auditory cues can enhance learning. Visual aids like charts and diagrams, along with verbal explanations, can cater to different learning styles. This approach promotes better retention and understanding.
Incorrect options: A: Incorporating teaching needs into one daily session may overwhelm the older adult. C: Closing the door may create a sense of isolation. D: Beginning with the most difficult tasks can be discouraging and hinder learning progress.
A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy. When the nurse enters the client's room, he states that, following a bout of coughing, 'something popped in my belly.' The nurse lifts the sheets and sees that the client's gown is bloody. After sending a coworker to get the charge nurse and call the surgeon, which of the following actions should the nurse take next?
- A. Position the client supine with his hips and knees bent.
- B. Prepare to administer an IV infusion of 0.9% sodium chloride.
- C. Cover the wound with moist sterile gauze.
- D. Measure the client's vital signs.
Correct Answer: C
Rationale: Evisceration requires immediate covering of the wound with a sterile, moist dressing to prevent infection and tissue damage.
A nurse is caring for a client who has pneumonia. The nurse should place the client on his right side in Trendelenburg position to help mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right lower lobe
Correct Answer: D
Rationale: The Trendelenburg position promotes drainage of secretions from specific lung segments, improving oxygenation.
A nurse is caring for a school-age child who has metastatic osteosarcoma. While the parents are away, the child is crying and asks the nurse if she is going to die. Which of the following is an appropriate response by the nurse?
- A. Let's talk about what activities you are going to participate in tomorrow.
- B. This is something you should discuss with your parents when they return.
- C. Let's talk about it. Tell me more about what you are thinking.
- D. You need to focus on getting better instead of what may or may not happen.
Correct Answer: C
Rationale: Encouraging the child to express feelings allows the nurse to provide emotional support.
A nurse is talking with a client who is beginning a program of moderate exercise. When the nurse reminds the client of the importance of doing warm-up exercises, the client asks why. Which of the following reasons should the nurse give?
- A. Stabilizes body temperature
- B. Enhances relaxation
- C. Reduces the risk of injury
- D. Readjusts to baseline function
Correct Answer: C
Rationale: The correct answer is C: Reduces the risk of injury. Warm-up exercises help increase blood flow to muscles, making them more flexible and responsive. This reduces the risk of muscle strains and injuries during exercise. Choice A is incorrect because while warm-up exercises may help regulate body temperature during exercise, that is not the primary reason for warm-ups. Choice B is incorrect as the primary purpose of warm-up exercises is not necessarily to enhance relaxation. Choice D is incorrect as warm-up exercises do not specifically readjust to baseline function; they prepare the body for exercise.