Nokea
A standard walker is used when clients:
- A. have poor balance, cannot stand up, have weak arms, and have good hand strength.
- B. have poor balance, have a broken leg, or have experienced amputation.
- C. have poor balance, have cardiac problems, or cannot use crutches or a cane.
- D. have poor balance, have an autoimmune disease, or have weak arms.
Correct Answer: C
Rationale: A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward.
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A client is to have an enema to reduce flatus. The enema tube should be inserted:
- A. 4 inches.
- B. 6 inches.
- C. 2 inches.
- D. 8 inches.
Correct Answer: A
Rationale: Enema tubing must be passed beyond the internal sphincter. Two inches is not far enough to pass the internal sphincter. Both 6 and 8 inches are too far and might cause trauma to the bowel.
Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?
- A. provide oxygen
- B. promote healthy nutritional practices
- C. treat complications of malnutrition
- D. increase weight
Correct Answer: B
Rationale: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems. Choice A is incorrect because it is a nursing intervention, not a goal statement. Choice C is incorrect because it is a therapeutic treatment. Choice D is incorrect because weight gain is an appropriate goal only if the client is underweight.
The client began wearing hearing aids 5 weeks earlier. Which statement to the nurse demonstrates that the client is successfully adapting to the hearing aids?
- A. I need to wear the hearing aids only when I go out in public.
- B. I clean my ears with a cotton-tipped swab before I insert them.
- C. I place the hearing aids in the protective box to store them at night.
- D. I soak the plastic parts of the hearing aids in mild soap and water weekly.
Correct Answer: C
Rationale: C: Hearing aids are expensive and delicate, and they should be stored in a protective container in a dry, safe place. A: Hearing aids should be worn daily to adjust to their use. B: Cotton-tipped swabs should not be inserted into the ear canal due to possible injury and infection. D: Hearing aids should be kept dry except when cleaning the ear mold with mild soap and water.
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct Answer: D
Rationale: A back rub and warm milk promote relaxation and sleep. Vigorous exercise, cool showers, hot tea, and late TV watching are stimulating and disrupt sleep.
Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?
- A. You will not be allowed to see your family member after the post-mortem care is performed.
- B. I am not able to assist you, but we can call pastoral care if you need any comfort.
- C. Unfortunately, we are not allowed to incorporate any cultural practices in my preparations.
- D. I will be ensuring that your family member is properly identified before they are transported.
Correct Answer: D
Rationale: When providing post-mortem care, ensure the patient is properly identified and labeled before transporting. If possible, cultural practices should be incorporated, and the family should be allowed to see the client. When possible, the nurse should provide comfort to the family.