Nokea
A young adult is discharged to home with crutches. Which exercise should the nurse teach the client in order to strengthen the hand muscles for crutch walking?
- A. Pushing the buttocks up off the mattress
- B. Pulling the body up, using an overhead trapeze
- C. Raising the legs straight up and down
- D. Squeezing a rubber ball in each hand
Correct Answer: D
Rationale: Squeezing a rubber ball strengthens hand muscles, essential for gripping crutches during walking.
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In this case, from whom is it most appropriate for the physician, with the nurse as a witness, to obtain consent to perform the surgical procedure?
- A. The client
- B. The client's physician
- C. The client's youth leader
- D. The client's parent
Correct Answer: D
Rationale: A 17-year-old is typically a minor, requiring parental consent for surgical procedures unless emancipated or in an emergency where consent cannot be obtained. The client, physician, or youth leader cannot provide legal consent.
It is necessary to pull the client, who is in Russell's traction, up in bed. Which action should the nurse take?
- A. Leave the weights in place.
- B. Remove the weights completely.
- C. Reduce the weight of the traction by one half.
- D. Have one nurse lift the weights while the others pull the client.
Correct Answer: A
Rationale: Leaving weights in place maintains continuous traction, preventing misalignment during repositioning.
The client diagnosed with rule-out osteosarcoma asks the nurse, 'Why am I having a bone scan?' Which statement is the nurse’s best response?
- A. You seem anxious. Tell me about your anxieties.'
- B. Why are you concerned? Your HCP ordered it.'
- C. I’ll have the radiologist come back to explain it again.'
- D. A bone scan looks for cancer or infection inside the bones.'
Correct Answer: D
Rationale: A bone scan detects cancer or infection, directly answering the client’s question. Addressing anxiety, deferring to the HCP, or radiologist involvement is less informative.
How can the nurse best support the wet cast while the physician wraps the arm with rolls of wet plaster?
- A. By using a soft mattress
- B. By resting it on a firm surface
- C. By using the client's knee on the fingers
- D. By using the palms of the hands
Correct Answer: D
Rationale: Using the palms of the hands to support the wet cast prevents indentations that could cause pressure points, ensuring the cast maintains its shape. A soft mattress or fingers may deform the cast, and a firm surface is less precise.
The nurse assesses the client 6 hours following a lumbar spinal fusion. The client has a throbbing headache, but VS and CMS of the lower extremities are WNL. The lungs have fine basilar crackles. The back dressing has a dime-sized bloody spot surrounded by clear yellow drainage. Which nursing action demonstrates the nurse's best clinical judgment?
- A. Give prescribed morphine sulfate IV
- B. Have the client cough and deep breathe
- C. Reinforce the incisional dressing
- D. Notify the health care provider
Correct Answer: D
Rationale: D. A bloody area surrounded by clear yellowish fluid on the dressing and the client's headache suggest a CSF leak. The nurse should notify the HCP.