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As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
- A. Place the client in a wheelchair to protect their safety in the clinic.
- B. Remove the cane from the client to protect their safety.
- C. Teach the client about the proper length of a cane.
- D. Have the client use a wheelchair rather than the cane.
Correct Answer: C
Rationale: Educating the client about the proper cane length (typically where the handle reaches the wrist when the arm is at the side) promotes safety and proper use without unnecessarily restricting mobility.
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The nurse caring for a client after shoulder arthroplasty for rheumatoid arthritis monitors the client for brachial plexus compromise. To assess the status of the median nerve, which action would the nurse perform?
- A. Have the client spread all of the fingers wide and resist pressure.
- B. Monitor for flexion of the biceps by having the client raise the forearm.
- C. Have the client move the thumb toward the palm and back to the neutral position.
- D. While grasping the nurse's hand, note the strength of the client's first and second fingers.
Correct Answer: D
Rationale: To assess the median nerve status, the client should be instructed to grasp the nurse's hand. The nurse should note the strength of the client's first and second fingers. A weak grip may indicate compromise of the median nerve. Asking the client to spread all fingers wide and resist pressure assesses the ulnar nerve status. Monitoring for flexion of the biceps by raising the forearm assesses the cutaneous nerve status. Asking the client to move the thumb toward the palm and back to neutral position assesses the radial nerve status.
The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?
- A. Bring the child to the emergency department immediately.
- B. It is not an emergency, but it is best to call the health care clinic.
- C. It is important to replace them immediately so that the surgical opening does not close.
- D. Clean the tubes with half-strength hydrogen peroxide for 30 minutes and then replace them into the child's ears.
Correct Answer: B
Rationale: The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.
The nurse should instruct the client prescribed docusate to monitor for which intended effect of the medication?
- A. Abdominal pain
- B. Decreased heartburn
- C. Decrease in fatty stools
- D. Regular bowel movements
Correct Answer: D
Rationale: Docusate is a stool softener that promotes absorption of water into the stool, producing a softer consistency of stool. The intended effect is relief or prevention of constipation. The medication does not relieve abdominal pain, relieve heartburn, or decrease the amount of fat in the stools.
Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which of the following complications?
- A. Hypostatic pneumonia.
- B. Pulmonary hypertension.
- C. Orthostatic hypotension.
- D. Fluid imbalances.
Correct Answer: D
Rationale: TPN can cause fluid imbalances due to high glucose and volume loads, requiring close monitoring of intake, output, and electrolytes.
A client with a history of heart failure is prescribed metoprolol (Lopressor). The nurse should monitor the client for which of the following adverse effects?
- A. Bradycardia.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Metoprolol, a beta-blocker, can cause bradycardia, requiring heart rate monitoring.