Nokea
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.
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The nurse is preparing to assist with a lumbar puncture for a client with suspected meningitis. Which of the following positions should the nurse place the client in?
- A. Supine with the head elevated.
- B. Prone with the head turned to one side.
- C. Side-lying with knees flexed to the chest.
- D. Sitting with the back arched.
Correct Answer: C
Rationale: side-lying with knees flexed to the chest maximizes spinal flexion, facilitating access to the subarachnoid space
Which clients can be assigned to share a room in the emergency department during the disaster?
- A. A client having auditory hallucinations and the client with ulcerative colitis
- B. The client who is pregnant and the client with a broken arm
- C. A child who is cyanotic with severe dypsnea and a client with a frontal head injury
- D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Correct Answer: B
Rationale: The pregnant client and the client with a broken arm have stable conditions, making them suitable to share a room.
The nurse is assisting a client to adjust crutches to the proper measurement. With the client in standing position, where should the tips of the crutches be placed?
- A. 2 to 3 inches directly to the side of the client's legs
- B. 4 to 6 inches to the side of the client's legs and 4 to 6 inches in front of feet
- C. 2 to 3 inches to the side of the client's legs and 4 to 6 inches in front of feet
- D. 4 to 6 inches directly to the side of the client's legs
Correct Answer: B
Rationale: Crutch tips should be 4-6 inches to the side and 4-6 inches in front of the feet (B) for stability and balance.
The nurse is assessing for abdominal pulsations in a client with a visible mass below the umbilicus. The nurse should use which technique?
- A. light palpation
- B. inspection
- C. percussion
- D. deep palpation
Correct Answer: B
Rationale: Inspection is used to visually assess for abdominal pulsations or masses. Palpation or percussion may be used later but are not the initial technique for observing pulsations.
The nurse should explain to a client that tolbutamide (Orinase) is effective for diabetics who
- A. can no longer produce any insulin.
- B. produce minimal amounts of insulin.
- C. are unable to administer their injections.
- D. have a sustained decreased blood glucose.
Correct Answer: B
Rationale: oral hypoglycemic agents are administered to type II (non-insulindependent) clients who are able to produce minimal amounts of insulin