Nokea
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will move the cane forward 18 inches.
- B. I will hold the cane on my stronger side.
- C. I should wear shoes with smooth soles to help slide my weak leg forward.
- D. I should move my stronger leg forward before moving my weaker leg.
Correct Answer: B
Rationale: Holding the cane on the stronger side provides optimal support and balance for the weaker side.
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A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Dangle your legs over the side of the bed.
- B. Use your incentive spirometer.
- C. Increase your intake of protein.
- D. Perform regular isometric exercises.
Correct Answer: A
Rationale: Dangling legs before standing allows gradual adjustment to upright posture, reducing orthostatic hypotension risk.
A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Keep their arms at the sides of their body with their hands in a relaxed position.
- B. Interlock their fingers and hold their hands away from their body above their waist.
- C. Clasp their hands together in a relaxed position behind their body at their waist.
- D. Place one hand over the other against the part of the gown covering their upper body.
Correct Answer: B
Rationale: Interlocking fingers above the waist keeps hands sterile and away from contamination.
A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Conduct staff communications away from the client's room.
- B. Turn off alarms on bedside monitoring equipment.
- C. Avoid entering the client's room unless requested during the night.
- D. Turn on the client's TV to distract from hallway noise.
Correct Answer: A
Rationale: Reducing noise by moving staff communication away enhances sleep without compromising safety.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 5
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg ÷ 125 mg/5 mL = 12.5 mL/day; 12.5 ÷ 4 = 3.125 mL, rounded to 5 mL.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Check the client's skin integrity every 4 hr.
- C. Tie the belt restraint to the side rail of the bed.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown prevents skin irritation and ensures proper fit per safety guidelines.