Nokea
A nurse is teaching a client how to use crutches. Which of the following interventions uses the psychomotor domain of learning?
- A. Describe the steps of walking with crutches for the client
- B. Encourage the client to ask questions about walking with crutches
- C. Show the client a video on walking with crutches
- D. Ask the client to demonstrate walking with crutches
Correct Answer: D
Rationale: The correct answer is D: Ask the client to demonstrate walking with crutches. This intervention engages the psychomotor domain of learning by requiring the client to physically demonstrate the skill being taught. This hands-on approach helps the client develop muscle memory and coordination needed to effectively use crutches.
A, B, and C do not directly involve physical action or demonstration by the client. A describes verbal instruction, B encourages questioning and discussion, and C involves visual learning through a video. While these interventions are valuable in the learning process, they do not specifically target the physical practice of using crutches.
In summary, option D is the correct choice as it actively engages the client in practicing the skill, aligning with the psychomotor domain of learning.
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A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
- A. The client who has a nasogastric (NG) tube to suction
- B. The client who has a chest tube to water seal
- C. The client who has an indwelling urinary catheter to gravity drainage
- D. The client who has a tracheostomy tube attached to humidified oxygen
Correct Answer: A
Rationale: The correct answer is A: The client who has a nasogastric (NG) tube to suction. Suctioning through the NG tube can lead to loss of gastric contents, including potassium, which can result in hypokalemia. The other choices do not directly affect potassium levels. B: A chest tube to water seal is used to drain air or fluid from the pleural space, not likely to cause hypokalemia. C: An indwelling urinary catheter to gravity drainage does not impact potassium levels. D: A tracheostomy tube with humidified oxygen does not affect potassium levels. Therefore, the client with the NG tube to suction is at risk for hypokalemia due to potential potassium loss.
A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following?
- A. Muscle mass
- B. Bone density
- C. Joint flexibility
- D. Muscle strength
Correct Answer: C
Rationale: Passive range of motion exercises are performed to maintain or improve joint flexibility in clients who are unable to move their joints independently. This helps prevent contractures and stiffness. Joint flexibility allows for better mobility and reduces the risk of injury. The other choices are incorrect because: A) Muscle mass is not directly affected by passive range of motion exercises. B) Bone density is not the primary focus of passive range of motion exercises. D) Muscle strength is not the main goal of passive range of motion exercises.
A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?
- A. Assessment
- B. Planning
- C. Evaluation
- D. Analysis
Correct Answer: B
Rationale: The correct answer is B: Planning. During the planning phase of the nursing process, the nurse collaborates with other healthcare professionals to develop a comprehensive discharge plan for the postoperative client. This involves setting goals, determining interventions, and outlining the necessary resources for a smooth transition from the hospital to home care. Assessment (choice A) involves collecting data, evaluation (choice C) involves determining the effectiveness of the plan, and analysis (choice D) involves breaking down information. In this scenario, the nurse is actively involved in creating a structured plan for the client's discharge, making choice B the correct answer.
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers. Which lab value would the nurse expect to see?
- A. Chloride 112
- B. Calcium 7.5
- C. Potassium 4.0
- D. Calcium 12.1
Correct Answer: B
Rationale: The correct answer is B: Calcium 7.5. With partial removal of the parathyroid gland, there may be decreased production of parathyroid hormone leading to hypocalcemia. Numbness and tingling in the hands and fingers are classic symptoms of hypocalcemia. A low calcium level of 7.5 is indicative of this condition.
Choice A: Chloride 112 is not related to symptoms of numbness and tingling.
Choice C: Potassium 4.0 is within the normal range and not associated with symptoms of hypocalcemia.
Choice D: Calcium 12.1 indicates hypercalcemia, not hypocalcemia, which would not cause numbness and tingling.
A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?
- A. Clean the skin near the drain in a circular motion from the outside to the inside
- B. Empty the drainage device when it is half full
- C. Place a perforated gauze pad around the drain to absorb drainage
- D. Connect the drain to continuous low-pressure suction
Correct Answer: C
Rationale: Rationale: Choice C is correct because placing a perforated gauze pad around the drain helps absorb drainage and prevents skin irritation. This promotes wound healing and prevents infection. Choice A is incorrect as it can introduce bacteria into the wound. Choice B is incorrect because drainage should be emptied when it reaches a certain level, not necessarily when it is half full. Choice D is incorrect as Penrose drains do not require suction.