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During passive range of motion (ROM) exercises, how should the nurse perform each movement for a patient with impaired mobility?
- A. The nurse moves each movement just to the point of resistance.
- B. The patient repeats each movement 5 times.
- C. The movement continues until the patient reports pain.
- D. The nurse completes each movement quickly and smoothly.
Correct Answer: A
Rationale: During passive range of motion (ROM) exercises, the nurse is responsible for moving the patient's joints through their range of motion. The correct technique involves performing movements slowly and smoothly, only going to the point of resistance without causing pain. This technique helps maintain joint flexibility and prevent contractures. Choice A is the correct answer as it reflects the appropriate technique for passive ROM exercises. Choices B and C are incorrect because the patient is not actively participating, and ROM exercises should not cause pain. Choice D is incorrect as movements should be done deliberately and not quickly.
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A client's readiness to learn about insulin administration is being assessed by a nurse. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
- A. ''I can concentrate best in the morning.''
- B. ''It is difficult to read the instructions because my glasses are at home.''
- C. ''I'm wondering why I need to learn this.''
- D. ''You will have to talk to my wife about this.''
Correct Answer: A
Rationale: Choice A is the correct answer because the client's statement about the best time to concentrate indicates readiness for learning. This statement shows an awareness and interest in learning. Choice B is incorrect as it indicates a barrier to learning due to not having glasses. Choice C is incorrect as it shows a lack of understanding or motivation for learning. Choice D is incorrect as it suggests a lack of personal involvement or responsibility in the learning process since the client is deflecting the responsibility to someone else.
When should discharge planning for a client experiencing an exacerbation of heart failure be initiated?
- A. During the admission process
- B. After the client is stabilized
- C. When the client expresses readiness to go home
- D. Just before the expected discharge date
Correct Answer: A
Rationale: Discharge planning for a client with an exacerbation of heart failure should begin during the admission process. Initiating discharge planning early ensures a smooth transition and continuity of care for the client. Option B, after the client is stabilized, is not ideal because planning should start early to address potential barriers to discharge. Option C, when the client expresses readiness to go home, may be too late as discharge planning is a proactive process. Option D, just before the expected discharge date, does not allow enough time for comprehensive planning and coordination of post-discharge care needs.
When admitting a client, what information should the nurse record in the client's record first?
- A. Assessment of the client
- B. Client's medical history
- C. Plan of care
- D. Vital signs
Correct Answer: A
Rationale: When admitting a client, the nurse's first step should be to assess the client. Assessment is crucial as it helps establish a baseline of the client's condition, identify any immediate concerns, and guide the development of an individualized plan of care. Recording the client's medical history, plan of care, or vital signs may follow the initial assessment but are secondary to the primary assessment process.
The client with congestive heart failure (CHF) is receiving furosemide (Lasix). Which laboratory value should the healthcare provider monitor closely?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Magnesium
Correct Answer: A
Rationale: Correct! When a client is taking furosemide (Lasix), monitoring potassium levels is crucial due to the potential for hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Low potassium levels can predispose the client to cardiac dysrhythmias. Sodium, calcium, and magnesium levels are not typically affected by furosemide to the same extent as potassium, making them less critical to monitor in this scenario.
A nurse is talking with caregivers of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority?
- A. "We just don't understand why our child can't keep up with the other kids in simple activities like running and jumping."
- B. "Our child keeps trying to find ways around our household rules. They always want to make deals with us."
- C. "We think our child is trying too hard to excel in math just to get the top grades in the class."
- D. "Our child likes to sing and worries it will make the other kids want to laugh."
Correct Answer: A
Rationale: The correct answer is A. Difficulty in keeping up with physical activities like running and jumping may indicate an underlying physical or developmental issue that requires prompt assessment. This could be related to musculoskeletal problems, coordination difficulties, or other health concerns that need further evaluation. Choices B, C, and D, while important, do not address a potential physical or developmental issue that could impact the child's overall well-being. Addressing the child's physical limitations should be the priority to ensure appropriate support and intervention.