Nokea
If a client has had repair of a right fractured hip and has an overhead trapeze on the bed to assist with movement, which of the following instructions should the client receive about use of the assistive device? Select all that apply.
- A. The client should always grasp the bar with both hands before moving.
- B. The client should grasp the bar with the left hand and place the right hand flat on the bed to assist movement.
- C. The client should flex the left hip and knee and place the foot flat on the bed before moving.
- D. The client should keep the left hip and knee extended when moving.
Correct Answer: A,C
Rationale: Using both hands on the trapeze (A) and flexing the left leg (C) assist safe movement post-right hip repair. Using one hand (B) or keeping the leg extended (D) is less effective.
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The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. The nurse is aware that Pitocin is working if the fundus is:
- A. Deviated to the left.
- B. Firm and in the midline.
- C. Boggy.
- D. Two finger breadths below the umbilicus.
Correct Answer: B
Rationale: A firm and midline fundus indicates effective uterine contraction, showing Pitocin is working to prevent postpartum hemorrhage.
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- A. Oral mucous membrane, altered related to chemotherapy
- B. Risk for injury related to thrombocytopenia
- C. Fatigue related to the disease process
- D. Interrupted family processes related to life-threatening illness of a family member
Correct Answer: B
Rationale: Thrombocytopenia in acute leukemia increases the risk of bleeding, making 'risk for injury' the priority diagnosis to ensure patient safety.
A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?
- A. Head of bed elevated 30°-45°.
- B. Head of bed elevated 60°-90°.
- C. Side-lying with head elevated 15°.
- D. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: facilitates swallowing and movement of tube through GI tract
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
- A. Serum collection (Davol) drain
- B. Client's pain
- C. Nutritional status
- D. Immobilizer
Correct Answer: B
Rationale: Pain assessment is a priority post-surgery to manage discomfort and detect complications.
A nurse performing a newborn assessment would expect what respiratory rate and heart rate as a normal finding?
- A. RR 15 breaths/minute, HR 72 beats/minute
- B. RR 35 breaths/minute, HR 96 beats/minute
- C. RR 46 breaths/minute, HR 153 beats/minute
- D. RR 68 breaths/minute, HR 137 beats/minute
Correct Answer: C
Rationale: Newborns have a respiratory rate of 30-60 breaths/min and heart rate of 120-160 beats/min. Option C (RR 46, HR 153) is within normal ranges.