Nokea
The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene?
- A. Hold a crutch in each hand for support when standing up from a chair
- B. Move to the edge of the chair before standing and use the unaffected leg to rise
- C. Touch the back of the unaffected leg to the chair before preparing to sit
- D. Use an armrest or seat for assistance when lowering the body into a chair
Correct Answer: A
Rationale: Holding a crutch in each hand is incorrect as crutches should be placed together on the unaffected side or against a stable surface to free the hands for support when standing. Other instructions (B, C, D) are correct for safe crutch use during sitting and standing.
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The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first?
- A. Client after a colonoscopic polypectomy today with abdominal cramping and a small amount of rectal bleeding
- B. Client after a laparoscopic inguinal hernia repair yesterday who reports urinary hesitancy while voiding
- C. Client after a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement
- D. Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C)
Correct Answer: D
Rationale: A fever of 100.9 F post-arteriovenous graft suggests possible infection, requiring immediate assessment. Cramping and minor bleeding are expected post-polypectomy, urinary hesitancy is common post-hernia repair, and straining is less urgent.
The client is receiving a gentamicin IV. Which finding may indicate an adverse response to gentamicin?
- A. Decreased urine output
- B. Blurred vision
- C. Orange sputum
- D. Hypertension
Correct Answer: A
Rationale: Gentamicin is nephrotoxic; decreased urine output suggests kidney injury, a serious adverse effect. Other symptoms are not typically associated.
While sitting in the cafeteria, a nurse overhears two students discussing a client admitted for chemical detoxification. The nurse should:
- A. Report the incident to the teacher.
- B. Report the incident to the nursing supervisor.
- C. Confront the students with their behavior.
- D. Ignore the students' behavior.
Correct Answer: C
Rationale: Confronting the students addresses the breach of confidentiality directly and educates them. Reporting to the teacher or supervisor escalates unnecessarily, and ignoring the behavior allows the violation to persist.
A client is experiencing an exacerbation of chronic lower back pain after working in the yard all weekend. The nurse should reinforce the primary importance of which nonpharmacologic intervention for acute muscle pain?
- A. Heating pad
- B. Positioning for comfort
- C. Rest from pain-aggravating activities
- D. Stretching exercises
Correct Answer: C
Rationale: For acute lower back pain, rest from aggravating activities is primary to prevent further strain. Heat and positioning are helpful but secondary, and stretching may worsen acute pain.
A client with Parkinson's disease complains of 'choking' when he swallows. Which intervention will improve the client's ability to swallow?
- A. Withholding liquids until after meals
- B. Providing semi-liquids when possible
- C. Providing a full liquid diet
- D. Offering small, more frequent meals
Correct Answer: B
Rationale: Semi-liquids are easier to swallow for Parkinson's patients with dysphagia. Withholding liquids risks dehydration. Full liquid diets may be too thin. Small meals help nutrition but not swallowing.