Nokea
A nurse is caring for a client who is postoperative following a liver biopsy.
In which of the following positions should the nurse place the client immediately following the procedure?
- A. Trendelenburg
- B. Prone
- C. Right lateral
- D. High-fowlers
Correct Answer: C
Rationale: The correct answer is C: Right lateral. Placing the client in the right lateral position immediately following a procedure helps prevent aspiration of secretions or blood, as gravity assists in drainage from the airway. Trendelenburg position (A) is used to increase venous return but is not appropriate post-procedure. Prone position (B) is lying face down and may obstruct airway patency. High-fowlers position (D) is sitting upright at a 90-degree angle, which is not ideal for immediate post-procedure care.
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A nurse is providing teaching about home safety to an adult child of an older adult client who is postoperative following knee replacement surgery.
Which of the following instructions should the nurse include?
- A. Mark the edges of the doorway to the house with tape.
- B. Remove loose rugs from the home to prevent falls.
- C. Place soft cushions on all chairs to reduce discomfort.
- D. Install bright overhead lighting in the bedroom only.
Correct Answer: B
Rationale: The correct answer is B: Remove loose rugs from the home to prevent falls. This instruction is crucial in preventing falls, especially for elderly individuals who may have balance issues. Loose rugs are a common tripping hazard and removing them can significantly reduce the risk of falls. Marking the edges of the doorway with tape (A) may not be effective in preventing falls as it does not address the actual hazards. Placing soft cushions on all chairs (C) does not directly address fall prevention and may not be suitable for all individuals. Installing bright overhead lighting in the bedroom only (D) is important for visibility but does not address other fall risks in the home.
A nurse in an outpatient clinic is caring for a client.
Assessment
0840:
Client is calm and cooperative. Skin warm and dry. No rash noted. Lung sounds clear. Abdomen
soft to palpation with fundal height at 20 cm. Fetal heart rate 150/min. Bowel sounds active in all
four quadrants. No edema to lower extremities. Client denies visual changes or severe headaches.
Weight gain of 1.8 kg (4 lb) since last visit. Small amount of mucoid discharge noted on perineal
pad
Laboratory Results
0900:
Urine dipstick:
pH 6.0 mg/d (4.6 to 8 mg/dL)
Specific Gravity 1.022 (1.010 to 1.025)
Leukocyte esterase negative (Negative)
Nitrite negative (Negative)
Protein trace negative (Negative)
Glucose negative (Negative)
Ketones none (None)
Bilirubin none (None)
Blood none (None)
Nurses' Notes
0830:
Client reports to clinic for monthly prenatal visit. Client is at 20 weeks of gestation. Since last
visit, client reports concerns about the occurrence of intermittent mild backaches, increased
heartburn, generalized itching, and vaginal discharge.
Vital Signs
0830:
BP 124/68 mm Hg
Heart rate 80/min
Temperature 37° C (98.6° F)
Respiratory rate 16/min
Weight 67.1 kg (148 lb)
Which of the following statements should the nurse include in the client's teaching?
- A. Take hot showers to help relieve itching
- B. Wear flat or low-heeled shoes
- C. You can douche twice weekly
- D. Wear loose-fitting clothing
- E. Try using an abdominal support belt
- F. You should avoid fried foods
- G. Eat two large meals a day
Correct Answer: B,D,F
Rationale: Wearing flat shoes, wearing loose-fitting clothes, and avoiding fried foods are beneficial practices during pregnancy.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Instruct the client to avoid five vaccines
- B. Instruct the client to avoid foods high in purines
- C. Instruct the client to use mild soaps for cleansing skin.
- D. Gout
- E. Rheumatoid arthritis (RA)
- F. Systemic lupus erythematosus (SLE)
- G. ANA
Correct Answer: B
Rationale: Gout is characterized by elevated uric acid levels and responds to dietary modifications. Monitoring uric acid ensures treatment effectiveness.
A nurse in an acute care mental health facility is placing a client in seclusion and restraints.
Which of the following actions should the nurse plan to take?
- A. Document the client's behavior every 15 minutes.
- B. Obtain a prescription for restraints within 4 hours.
- C. Release the restraints every 2 hours to assess circulation.
- D. Discontinue restraints only when the provider removes the order.
Correct Answer: C
Rationale: The correct answer is C: Release the restraints every 2 hours to assess circulation. This action is essential to prevent complications related to impaired circulation and tissue damage. Releasing the restraints allows the nurse to assess the client's circulation, skin integrity, and comfort. It promotes safety and prevents potential harm.
Choice A (Document the client's behavior every 15 minutes) is not the best action as it focuses on behavior rather than safety and circulation. Choice B (Obtain a prescription for restraints within 4 hours) is not necessary as restraints should only be used if all other options have been exhausted. Choice D (Discontinue restraints only when the provider removes the order) is incorrect as the nurse should assess the client's condition independently and not solely rely on provider orders.
Admission Assessment
Client reports new onset of fever and discomfort in their joints and increase malaise. No relevant
medical history. Client is alert to person, place, time, and situation. Reports generalized pain as 4
on a scale of 0 to 10. Macular rash present on cheeks bilateral. Lungs clear anterior and posterior.
Bowel sounds active in all 4 quadrants. Last bowel movement 1 day ago. Skin warm, dry, and
intact. Capillary refill less than 3 seconds. A 20-gauge IV saline lock inserted in back left hand
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Ensure that client has intake of at least 200mL/hr
- B. Initiate contact precautions
- C. Prepare client for light therapy
- D. Sickle cell crisis
- E. Psoriasis
- F. Osteomyelitis
Correct Answer: B,C
Rationale: Increased fluid intake and contact precautions are essential for managing systemic lupus erythematosus.