Nokea
The hydraulic lift (Hoyer lift) is:
- A. used for all clients who've had orthopedic surgery.
- B. used for all clients who are not able to stand and for extremely obese clients.
- C. used for all clients, both old and young, in a hospital setting.
- D. not an assistive device for special needs.
Correct Answer: B
Rationale: The hydraulic lift is used for safe transfer when a client is not able to stand or is too heavy for the health care workers to lift safely.
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A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:
- A. standing the client and walking him or her to the wheelchair.
- B. moving the wheelchair close to client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
- C. moving the wheelchair close to client's bed and standing and pivoting the client on his affected extremity to the wheelchair.
- D. having the client stand and push his body to the wheelchair.
Correct Answer: B
Rationale: Moving the wheelchair close to client's bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.
The nurse is caring for the client with a stage III pressure ulcer to the right heel. Which actions should the nurse plan? Select all that apply.
- A. Encourage foods high in vitamin C such as orange juice
- B. Premedicate with analgesics prior to dressing changes
- C. Monitor pedal pulses and capillary refill of affected extremity
- D. Use hydrogen peroxide for cleaning of the ulcer wound
- E. Turn and reposition the client every 1 to 2 hours
- F. Elevate the extremity on pillows, keeping the heel off the pillow
Correct Answer: A,B,C,E,F
Rationale: A: Vitamin C aids wound healing. B: Analgesics improve comfort. C: Pulse checks detect vascular issues. E: Repositioning prevents further breakdown. F: Elevation and offloading reduce pressure. D: Hydrogen peroxide harms tissue.
Which of the following statements is true about syphilis?
- A. The cause and mode of transmission is unclear
- B. There is no known cure for the disease
- C. When the primary lesion heals, the disease is cured
- D. Syphilis can be cured with a course of antibiotic therapy
Correct Answer: D
Rationale: Syphilis is an acute and chronic treponemal disease that can be cured with antibiotics, such as a single IM dose of long-acting penicillin G (benzathine penicillin) for primary, secondary, or early latent syphilis. The cause and transmission (sexual contact) are clear, and healing of the primary lesion does not indicate a cure without treatment.
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.
The experienced nurse and the new nurse are preparing to provide phototherapy to the 4-day-old infant with hyperbilirubinemia. Which information should the experienced nurse include when instructing the new nurse about providing phototherapy for the infant?
- A. Keep the infant fully clothed to prevent chilling and hypothermia.
- B. Cover the infant's eyes with eye shields to prevent retinal damage.
- C. Limit the number of feedings to reduce the number of soiled diapers.
- D. Discontinue the phototherapy if the infant develops a mild skin rash.
Correct Answer: B
Rationale: B: Eye shields protect retinas from phototherapy light. A: Clothing reduces skin exposure, hindering bilirubin conversion. C: Increased feedings aid bilirubin excretion. D: Mild rashes are harmless and don't warrant discontinuation.