Nokea
An older man is seen in the outpatient clinic for treatment of an acute attack of gout.
- A. Which nursing intervention is most beneficial for decreasing pain during ambulation in a client with gout?
- B. Perform passive range-of-motion exercises before walking.
- C. Encourage partial weight bearing while ambulating.
- D. Immobilize the extremity between activities.
- E. Restrict the amount of time and the distance the man walks.
Correct Answer: B
Rationale: Partial weight bearing reduces pressure and stress on the affected joint, alleviating gout-related pain during ambulation. Passive exercises may worsen pain, immobilization increases stiffness, and restricting walking does not address pain management during necessary movement.
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Which of the following nursing actions should be the priority for an infant admitted with a positive stool culture for Salmonella?
- A. Change the diet to clear liquids.
- B. Initiate intravenous fluids.
- C. Maintain contact precautions.
- D. Apply cloth diapers.
Correct Answer: C
Rationale: prevents transmission of this bacterium to other individuals
The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following would be an appropriate nursing goal for this client?
- A. Decrease inflammatory response in the affected extremity and prevent embolus formation.
- B. Increase peripheral circulation and oxygenation of the affected extremity.
- C. Prepare the client and family for anticipated vascular surgery on the affected extremity.
- D. Prevent hypoxia associated with the development of a pulmonary embolus.
Correct Answer: A
Rationale: important to prevent the complication of pulmonary embolism in clients at high risk
The nurse is supervising a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the correct procedure?
- A. The Levin tube remains unclamped for 30 minutes after the feeding.
- B. Sterile equipment is used to administer the feeding.
- C. The amount of the feeding is varied according to the patient's tolerance.
- D. The tube feeding is given at room temperature.
Correct Answer: D
Rationale: minimizes intestinal cramping
The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome?
- A. Prevent iron deficiency anemia.
- B. Decrease touch to prevent overstimulation.
- C. Provide feedings via gavage to decrease energy expenditure.
- D. Replace vitamins depleted as a result of poor maternal diet.
Correct Answer: D
Rationale: frequently, maternal diet is poor, and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function
The nurse is caring for a toddler in traction, and the toddler is receiving chloral hydrate (Noctec). The toddler becomes irritable and extremely restless. Which nursing action is MOST appropriate?
- A. Give the next dose of chloral hydrate early.
- B. Contact the physician to obtain new orders.
- C. Instruct the toddler's mother to read to him.
- D. Take the toddler out of traction for 30 minutes.
Correct Answer: B
Rationale: Irritability and restlessness suggest a paradoxical reaction to chloral hydrate, requiring physician notification for medication adjustment. Options A, C, and D are unsafe or ineffective.