Nokea
The client uses a walker to ambulate with partial weight-bearing after foot surgery. What should the nurse observe when this client is using the walker correctly?
- A. Has elbows bent at a 30-degree angle
- B. Is bent over the front bar of the walker
- C. While walking, lifts the walker 2 inches
- D. Has a walker that has four wheels in place
Correct Answer: A
Rationale: A: Elbows at 30 degrees indicate proper walker height. B: Bending over risks poor posture and falls. C: Lifting the walker prevents partial weight-bearing. D: Four-wheeled walkers are unsuitable for partial weight-bearing.
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To ensure proper immobilization and increase client comfort when using a rigid splint:
- A. place the client on a stretcher before splinting
- B. place the client on a long spine board before splinting
- C. pad the spaces between the body part and the splint
- D. ensure that the splint conforms to the body curves
Correct Answer: C
Rationale: Padding spaces in a rigid splint prevents pressure points, enhancing comfort and ensuring effective immobilization.
To remove a client's gown when she has an intravenous line, the nurse should:
- A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown.
- B. cut the gown with scissors.
- C. thread the bag and tubing through the gown sleeve, keeping the line intact.
- D. temporarily disconnect the tubing from the intravenous container and thread it through the gown.
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.
Which of these statements from the caregiver of a palliative care client indicates a proper understanding?
- A. This treatment plan usually means the prognosis is less than 6 months.
- B. We will need to stay in the hospital to receive this level of care.
- C. The main therapeutic goals are comfort and better quality of life.
- D. The medications to treat the underlying disease will be stopped.
Correct Answer: C
Rationale: The goal of palliative care is to make the client as comfortable as possible and not require a hospital stay. Prognoses vary and curative treatments can still be pursued during palliative care.
The method of splinting is always dictated by:
- A. Location of the injury and whether it is open or closed
- B. The severity of the client's condition and the priority decision
- C. The number of available rescuers and the type of splints
- D. All of the above
Correct Answer: B
Rationale: The severity of the client's condition and priority decision dictate splinting to ensure stabilization and prevent further injury, taking precedence over location or resources.
The client voided 300 mL after having an indwelling urinary catheter removed six hours ago. A bladder scan immediately after the void showed that the client has a postvoid residual (PVR) volume of 250 mL. What should the nurse conclude from this finding?
- A. This is an expected finding following catheter removal.
- B. The client's bladder function is approximately 50% of normal.
- C. The bladder scan was not done within 20 minutes of voiding.
- D. The PVR volume is evidence of incomplete bladder emptying.
Correct Answer: D
Rationale: D: A PVR of 250 mL indicates incomplete bladder emptying, as normal PVR is less than 50 mL. A: High PVR is not expected. B: PVR doesn't quantify bladder function percentage. C: No evidence suggests timing was incorrect.