Nokea
The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer a protein-rich diet
- C. Offer the client a bedpan for toileting
- D. Turn the client every 4 hours
Correct Answer: A
Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.
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The nurse is caring for 4 clients. Which of these clients will the nurse see first?
- A. A client with rheumatoid arthritis and a scheduled pain medication
- B. A client being discharged in 2 hours and needs to be taught how to use crutches
- C. A client with sudden and increasing pain in a fractured arm
- D. A client with a fractured ankle who would like a glass of water
Correct Answer: C
Rationale: The correct answer is C because sudden and increasing pain in a fractured arm indicates a potential complication that requires immediate attention to assess and manage. Choices A, B, and D do not present immediate life-threatening situations or emergent needs compared to sudden and increasing pain in a fractured arm, which takes priority to ensure the client's safety and comfort.
The client has been asked to perform weight-bearing exercises three times a week. The client admits to not doing the recommended exercises. What is the most appropriate response by the nurse?
- A. I walk 3 miles every day. Would you like to join me?
- B. Tell me more about your experience with these exercises.
- C. My dad never exercised. He fell and broke his hip. Is that your goal?
- D. You should be doing these exercises.
Correct Answer: B
Rationale: The most appropriate response by the nurse is to ask the client to elaborate on their experience with the exercises. By doing so, the nurse can gain insight into any barriers the client may be facing and work together to find solutions to improve adherence. Choice A is not appropriate as it doesn't address the client's situation. Choice C is not relevant and may induce fear in the client. Choice D is directive and does not promote open communication or understanding of the client's perspective.
What medication class can decrease tissue inflammation but delays bone healing?
- A. Anticoagulants
- B. Nonsteroidal anti-inflammatory drugs (NSAIDs)
- C. Opioids
- D. Narcotics
Correct Answer: B
Rationale: The correct answer is B: Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are known to decrease tissue inflammation but may delay bone healing. Anticoagulants (Choice A) are used to prevent blood clotting, opioids (Choice C) are pain relievers, and narcotics (Choice D) are drugs that affect the central nervous system. While all the choices may have their own indications and uses in healthcare, NSAIDs are specifically associated with delaying bone healing despite their anti-inflammatory properties.
The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?
- A. Two-point gait
- B. Three-point gait
- C. Four-point gait
- D. Unaffected gait
Correct Answer: B
Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.
Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?
- A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
- B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
- C. The UAP carefully empties the indwelling catheter bag
- D. The UAP shows the client how to use the call light
Correct Answer: A
Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.