Nokea
The client is being taught how to perform active range of motion (ROM) exercises. To exercise the hinge joints, which action should the client be instructed to perform?
- A. Tilt the pelvis forwards and backwards
- B. Bend the arm by flexing the ulnar to the humerus
- C. Turn the head to the right and left
- D. Extend the arm at the side and rotate it in circles
Correct Answer: B
Rationale: Hinge joints, like the elbow, primarily allow movement in one direction, in this case, bending the arm. The correct action to exercise hinge joints is to bend the arm by flexing the ulnar to the humerus. This movement specifically targets the hinge joint and promotes its range of motion. Choices A, C, and D involve movements that do not specifically target hinge joints. Tilt the pelvis involves the ball-and-socket joints of the hip, turning the head involves the pivot joint of the neck, and extending the arm and rotating it in circles involve multiple joints including ball-and-socket and pivot joints.
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After abdominal surgery, an adult is now alert and oriented. What position is most appropriate for the client?
- A. Semi-Fowler's
- B. Prone
- C. Supine
- D. Sim's
Correct Answer: A
Rationale: The most appropriate position for a client following abdominal surgery is Semi-Fowler's. This position promotes greater thoracic expansion and reduces pressure on the suture line, aiding in respiratory function and preventing strain on the incision site. Choices B, C, and D are incorrect. Prone position (Choice B) would not be suitable after abdominal surgery as it can put pressure on the abdomen. Supine position (Choice C) may cause discomfort and strain on the incision area. Sim's position (Choice D) is primarily used for rectal exams and enemas, which are unrelated to the needs post-abdominal surgery.
During the insertion of a nasogastric tube (NGT), the client begins to cough and gag. What action should the healthcare professional take?
- A. Stop advancing the tube and allow the client to rest
- B. Remove the tube and try again after a few minutes
- C. Continue inserting the tube while the client sips water
- D. Withdraw the tube slightly and pause before continuing
Correct Answer: D
Rationale: When a client begins to cough and gag during the insertion of a nasogastric tube, withdrawing the tube slightly and pausing is the appropriate action. This technique helps prevent further irritation, gives the client a moment to recover, and allows for a smoother continuation of the insertion process. Choice A is incorrect because allowing the client to rest without adjusting the tube position might not address the issue. Choice B is incorrect as removing the tube without addressing the cause of coughing and gagging may lead to repeated discomfort. Choice C is incorrect as continuing to insert the tube while the client is experiencing difficulties can increase discomfort and potential complications.
To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection?
- A. Ventrogluteal
- B. Outer upper quadrant of the buttock
- C. Two inches below the acromion process
- D. Vastus lateralis
Correct Answer: A
Rationale: The ventrogluteal site is the preferred location for administering large volume IM injections to avoid nerve injury. This site is situated away from major nerves and blood vessels, reducing the risk of complications associated with injecting into other areas. The ventrogluteal site allows for deep muscle penetration and is recommended for injections over 2 mL in volume to ensure proper dispersion and absorption of the medication. Choices B, C, and D are incorrect because the outer upper quadrant of the buttock is not the recommended site for large volume injections, two inches below the acromion process is a location for a deltoid injection, and the vastus lateralis is typically used for smaller volume injections.
An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first?
- A. Apply flannel pajamas to provide warmth.
- B. Administer a PRN dose of ibuprofen.
- C. Perform range of motion exercises in a warm tub.
- D. Drape the sheets over the footboard of the bed.
Correct Answer: D
Rationale: The correct answer is D. The nurse should first address the immediate comfort concern of the client, which is the weight of the linen on her legs causing severe joint pain. By draping the sheets over the footboard of the bed rather than tucking them under the mattress, the nurse can alleviate the pressure that the client perceives as the source of her pain. This action is a simple and effective way to provide relief and should be the initial step taken by the nurse. Choices A, B, and C do not directly address the client's immediate discomfort caused by the weight of the linen on her legs, making them less appropriate initial actions.
The healthcare professional is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the healthcare professional to implement?
- A. Stay with the client while the client is standing.
- B. Record the findings on the graphic sheet in the chart.
- C. Keep the blood pressure cuff on the same arm.
- D. Record changes in the client's pulse rate.
Correct Answer: A
Rationale: In obtaining a lie-sit-stand blood pressure reading, it is crucial for the healthcare professional to stay with the client while the client is standing. This action is the most important as it ensures client safety during the procedure. Recording findings, keeping the blood pressure cuff on the same arm, and monitoring pulse rate are all important tasks, but staying with the client while standing takes priority to prevent any potential falls or adverse events. By staying with the client, the healthcare professional can promptly address any signs of dizziness or instability, ensuring a safe environment for the client throughout the procedure.