Nokea
A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:
- A. standing the client and walking him or her to the wheelchair.
- B. moving the wheelchair close to client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
- C. moving the wheelchair close to client's bed and standing and pivoting the client on his affected extremity to the wheelchair.
- D. having the client stand and push his body to the wheelchair.
Correct Answer: B
Rationale: Moving the wheelchair close to client's bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.
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The dietitian prescribes a 24-hour calorie count for the malnourished hospitalized client. Which action should be taken by the nurse?
- A. Ask the client to recall at the end of the day the food and beverages consumed.
- B. Inform the client how to count the calories in the food and beverages consumed.
- C. Inform the client that a record will be maintained of food and beverages consumed.
- D. Ask the client to identify the food groups and foods that are being consumed in each.
Correct Answer: C
Rationale: C: Recording food intake ensures accurate calorie counts. A: Recall is unreliable. B: Clients don't calculate calories in hospital. D: Food groups don't provide calorie data.
Safety measures for using crutches must be taught to clients. Safety measures for the use of crutches include:
- A. properly fitting crutches with rubber tips at the end that provide a four-point gait.
- B. properly fitting crutches, education in the appropriate gait, and strength in the arms.
- C. crutches that fit the way the client chooses and a gait chosen by client.
- D. both legs touching the floor for all gaits.
Correct Answer: B
Rationale: In addition to the rubber tips on the ends of the crutches, the client needs to know the appropriate gait. Arm strength exercises are important, and it is critical that the client be fitted properly for the crutches.
The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?
- A. Wear sterile gloves to remove the lower plate first and then the upper plate.
- B. Use a foam swab to pry the upper and lower plates loose before removing these.
- C. Grasp the upper plate at the front teeth with a piece of gauze and move it prior to removal.
- D. Leave the dentures in the client's mouth and use a toothbrush to brush both denture plates.
Correct Answer: C
Rationale: C: Grasping the upper plate and moving it breaks the suction that holds the plate on the roof of the client's mouth. A: Removing denture plates is a clean procedure, and sterile gloves are not necessary. B: Removing the denture plates with a foam swab to pry the plate could injure the client. D: Dentures must be removed to properly clean the client's mouth and the dentures.
Hazards of improper splinting include:
- A. aggravation of a bone or joint injury
- B. reduced distal circulation
- C. delay in transport of a client with a life-threatening injury
- D. all of the above
Correct Answer: D
Rationale: Improper splinting can worsen injuries, impair circulation, and delay critical transport, posing significant risks to the client.
Following the change of shift report, the nurse should analyze the information and set priorities accordingly. When the plan has been formulated, at what point during the shift can or should the nurse's plan be altered or modified?
- A. halfway through the shift
- B. at the end of the shift before the nurse reports off
- C. when needs change
- D. after the top-priority tasks have been completed
Correct Answer: C
Rationale: The nurse should modify the care plan whenever the client's needs change to ensure responsive and effective care, rather than at fixed times or only after completing tasks.