Nokea
The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?
- A. The student should not be touching the plaster cast because it is wet.
- B. The student should be using a pillow to lift the client's casted extremity.
- C. The student is correctly handling a wet plaster cast with the palms.
- D. The student should be using fingers and not the palms to handle the cast.
Correct Answer: C
Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.
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An LPN is caring for a primarily bedridden client. Which finding should be of least concern?
- A. swollen feet
- B. brown discoloration above the ankles
- C. leg pain
- D. capillary refill time of 3 seconds on the big toe
Correct Answer: D
Rationale: Capillary refill time of longer than three seconds may indicate inadequate blood flow; capillary refill time of 2-3 seconds is a normal finding. Swollen feet, brown discoloration, and leg pain may be signs of venous insufficiency to the lower extremities.
The client residing in a nursing home has bilateral weak handgrips and visual and hearing deficits. Which interventions should the nurse implement when the client is eating a meal? Select all that apply.
- A. Ask the client's permission to open containers and cut up meats on the food tray.
- B. Obtain special easy-to-hold, built-up silverware for the client to use when eating.
- C. Observe the client, but avoid providing assistance even if the client is frustrated.
- D. Help feed the client if the client is eating too slowly so food does not get too cold.
- E. Ensure that the client wears eyeglasses and hearing aids before starting to eat.
Correct Answer: A,B,E
Rationale: A: Asking permission promotes autonomy. B: Built-up silverware aids weak grips. E: Sensory aids enhance independence. C: Assistance reduces frustration. D: Feeding discourages independence.
The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
- A. Pull the client toward you, and pivot him on the unaffected limb
- B. Pull the client toward you, and pivot him on the affected limb
- C. Push the client toward the bed, and pivot him on the affected limb
- D. Stand the client on both legs, and push him toward the bed
Correct Answer: A
Rationale: Pulling the client and pivoting on the unaffected limb ensures safety and leverages the client's stronger side for support.
A pregnant client has congenital heart disease. The nurse should expect to see which alterations in this client's diet during pregnancy?
- A. reduced calories and reduced fat
- B. caffeine and sodium restrictions
- C. decreased protein and increased complex carbohydrates
- D. fluid restriction and reduced calories
Correct Answer: B
Rationale: Caffeine and sodium restrictions are necessary to reduce cardiac strain and fluid retention in a pregnant client with heart disease, avoiding exacerbation of her condition.
Distraction therapy is:
- A. Focusing one's attention on stimuli other than pain
- B. Cognitive reappraisal
- C. The replacement of positive images of pain with other images
- D. The use of medication and meditation
Correct Answer: A
Rationale: The focus of distraction therapy is on positive stimuli rather than negative input, helping to manage pain perception.