Nokea
In this case, from whom is it most appropriate for the physician, with the nurse as a witness, to obtain consent to perform the surgical procedure?
- A. The client
- B. The client's physician
- C. The client's youth leader
- D. The client's parent
Correct Answer: D
Rationale: A 17-year-old is typically a minor, requiring parental consent for surgical procedures unless emancipated or in an emergency where consent cannot be obtained. The client, physician, or youth leader cannot provide legal consent.
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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.
It is necessary to pull the client, who is in Russell's traction, up in bed. Which action should the nurse take?
- A. Leave the weights in place.
- B. Remove the weights completely.
- C. Reduce the weight of the traction by one half.
- D. Have one nurse lift the weights while the others pull the client.
Correct Answer: A
Rationale: Leaving weights in place maintains continuous traction, preventing misalignment during repositioning.
The client is taking calcium carbonate (Tums) to help prevent further development of osteoporosis. Which teaching should the nurse implement?
- A. Encourage the client to take Tums with at least eight (8) ounces of water.
- B. Teach the client to take Tums with the breakfast meal only.
- C. Instruct the client to take Tums 30 to 60 minutes before a meal.
- D. Discuss the need to get a monthly serum calcium level.
Correct Answer: A
Rationale: Taking Tums with water ensures proper absorption and prevents GI irritation. Timing with meals is flexible, pre-meal timing is unnecessary, and monthly calcium levels are not routine.
The Muslim client practicing Islam is hospitalized following surgical repair of a hip fracture. The client informs the nurse about wishing to observe Ramadan, which is occurring now. Which statement by the nurse is respectful of the client's faith beliefs?
- A. I'm going to uncover your hip and leg now to check the incision and your pulses.'
- B. A dietitian helps to plan your meals so that meat and dairy products are not together.'
- C. I've asked that physical therapy be postponed until around 3 p.m., when Ramadan ends.'
- D. I should let the care team know not to bring food or beverages from sunrise to sunset.'
Correct Answer: D
Rationale: D. During the month of Ramadan, those of the Islamic faith do not eat or drink from sunrise to sunset.
The client is three (3) hours postoperative left AKA. The client tells the nurse, 'My left foot is killing me. Please do something.' Which intervention should the nurse implement?
- A. Explain to the client his left leg has been amputated.
- B. Medicate the client with a narcotic analgesic immediately.
- C. Instruct the client on how to perform biofeedback exercises.
- D. Place the client's residual limb in the dependent position.
Correct Answer: B
Rationale: Phantom limb pain is treated with analgesics; narcotics provide immediate relief. Explaining the amputation dismisses pain, biofeedback is long-term, and dependent positioning is inappropriate.