Nokea
If the client is in shock, how should the nurse position the client while continuing to assess and provide care?
- A. Prone with the arm supported
- B. In Fowler's position with the knees flexed
- C. Supine with the legs elevated
- D. Lateral with the back extended
Correct Answer: C
Rationale: Supine with legs elevated improves venous return in shock.
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The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client?
- A. The occupational therapist.
- B. The physiatrist.
- C. The recreational therapist.
- D. The home health nurse.
Correct Answer: D
Rationale: A home health nurse monitors recovery, manages complications, and supports mobility post-TKR. OT, physiatrists, and recreational therapists are less critical at discharge.
Which is most important for the nurse to include in the child's plan of care for a child with spina bifida (myelodysplasia)?
- A. Avoid the child's exposure to latex.
- B. Do intermittent urinary catheterization.
- C. Provide dietary fiber supplements daily.
- D. Complete a referral for physical therapy.
Correct Answer: A
Rationale: Avoiding latex exposure is critical due to the high risk of latex allergy in children with spina bifida.
The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse's priority?
- A. Presence of bruising to the right elbow
- B. Pain level rating on a 0-10 scale
- C. Sensation and pulse of the right forearm
- D. Left-handed or right-handed
Correct Answer: C
Rationale: C. Impairment of the neurovascular system is a priority. The closed reduction could cause further damage, which would be noted distal to the injury. Sensation and pulses are part of a neurovascular assessment to an extremity.
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.
Which staff nurse should the charge nurse assign to the client recovering from a repair of the hallux valgus?
- A. A new graduate nurse.
- B. An experienced nurse.
- C. A nurse practitioner.
- D. An unlicensed assistive personnel.
Correct Answer: B
Rationale: An experienced nurse is best suited for postoperative hallux valgus care, requiring skilled assessment. New graduates lack experience, NPs focus on advanced care, and UAPs cannot assess.