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Nurse delegating ambulation of client who had knee arthroplasty 5 days ago to an AP. Which of following info should nurse share with the AP? (Select all that apply.)
- A. The roommate is up independently
- B. Client ambulates with his slippers on over his antiembolic stockings
- C. Client uses front-wheeled walker when ambulating
- D. Client had pain med 30 min ago
- E. Client is allergic to codeine
- F. Client ate 50% of his breakfast this morning
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. The nurse should share that the client ambulates with slippers over antiembolic stockings (B) to ensure safety. The nurse should inform that the client uses a front-wheeled walker (C) to maintain stability during ambulation post-knee arthroplasty. Lastly, sharing that the client had pain medication 30 minutes ago (D) is crucial for the AP to monitor for potential side effects and adjust care accordingly.
Incorrect choices:
A: The roommate being up independently is irrelevant to the client's ambulation post-knee arthroplasty.
E: The client's allergy to codeine is important medical information but not essential for the AP to know when delegating ambulation.
F: The client's breakfast intake is not directly related to safe ambulation post-knee arthroplasty.
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Nurse reviewing CDC's immunization recommendations for young adult. Which should nurse include in this discussion?
- A. "HPV"
- B. measles, mumps, rubella
- C. varicella
- D. Haemophilus influenzae type b
- E. polio
Correct Answer: A, B, C
Rationale: The correct answer is A, B, C. The nurse should include these in the discussion because they are important immunizations recommended for young adults by the CDC. HPV vaccine helps prevent certain cancers; measles, mumps, rubella protects against these highly contagious diseases; varicella prevents chickenpox. The other choices, Haemophilus influenzae type b and polio, are not routinely recommended for young adults. Haemophilus influenzae type b is typically given in infancy, and polio is rare in the US due to successful vaccination programs.
Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which should be assigned to room closest to nursing station?
- A. 43 yo client post-op following laparoscopic cholecystectomy
- B. 61 yo client being admitted for telemetry to rule out MI
- C. 50 yo client post-op following open reduction internal fixation of ankle
- D. 79 yo client post-op following below-the-knee amputation
Correct Answer: D
Rationale: The correct answer is D. The 79 yo client post-op following below-the-knee amputation should be assigned to a room closest to the nursing station for fall prevention. This client may have mobility challenges, increased risk of falls due to recent surgery, and may require closer monitoring and immediate assistance if needed. Placing the client near the nursing station allows for quick response to any fall risk or postoperative complications.
A: The 43 yo client post-op following laparoscopic cholecystectomy is not at high risk for falls compared to the amputee.
B: The 61 yo client being admitted for telemetry to rule out MI does not necessarily have a higher fall risk than the amputee.
C: The 50 yo client post-op following open reduction internal fixation of ankle may have mobility limitations but is not as high risk for falls as the amputee.
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: Correct Answer: A,B,C,E
A: Helping the client see the benefits of their actions promotes motivation and adherence to health promotion strategies.
B: Identifying the client's support systems ensures they have a network to help maintain healthy behaviors and cope with stress.
C: Suggesting and recommending community resources expands the client's access to services that support cardiovascular health.
E: Teaching stress management strategies helps the client reduce risk factors associated with cardiovascular disease.
Incorrect Answer: D
Setting goals for the client without involving them in the process may not be effective in promoting long-term behavior change.
Nursing instructor explaining various stages of lifespan to students. Nurse should offer which following behavior by young adult as example of appropriate psychosocial development?
- A. "becoming actively involved in providing guidance to next generation"
- B. adjusting to major changes in roles/relationships due to losses
- C. devoting great deal of time to establishing occupation
- D. finding oneself 'sandwiched' between being responsible for 2 generations
Correct Answer: C
Rationale: The correct answer is C because young adults typically focus on establishing their occupation during this stage of development, as per Erikson's theory of psychosocial development. This behavior reflects the stage of intimacy vs. isolation, where individuals strive to form strong relationships and establish a sense of identity through their work. Choice A is incorrect as it pertains more to the generativity vs. stagnation stage, which occurs in middle adulthood. Choice B is incorrect as it aligns with the crisis of integrity vs. despair in late adulthood. Choice D refers to the sandwich generation, which involves caring for both children and aging parents, a challenge typically faced in middle adulthood.
Nurse educator is teaching module on proper body mechanics during employee orientation. Which statements by new nurse indicates need for more teaching?
- A. My line of gravity should fall outside my base of support
- B. The lower my center of gravity, the more stability I have
- C. To broaden my base of support, I should spread my feet apart
- D. When I lift an object, I should hold it as close to my body as possible
Correct Answer: A
Rationale: Rationale: A nurse's line of gravity should fall within the base of support, not outside, to maintain balance and prevent falls. Choice A is incorrect as it indicates a need for more teaching. Choices B, C, and D are correct statements that promote proper body mechanics. B explains the relationship between center of gravity and stability, C emphasizes broadening the base of support for better balance, and D suggests holding objects close to the body to reduce strain.