Nokea
The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?
- A. Assist the client to a sitting position at the edge of the bed
- B. Have the client march in place for 30 seconds
- C. Have the client raise his arms above his head
- D. Ask the client the last time he fell
Correct Answer: A
Rationale: The correct action to perform before ambulating a client post total knee replacement is to assist the client to a sitting position at the edge of the bed. This step is crucial to prevent orthostatic hypotension and ensure the client is ready to stand and walk safely. Having the client march in place or raise his arms above his head are not necessary preparations for ambulation. While knowing about the client's fall history is important for safety reasons, it is not the priority action immediately before ambulating the client.
You may also like to solve these questions
What is pica?
- A. dependency on alcohol
- B. increased iron in the diet
- C. the sickle cell trait
- D. eating ice
Correct Answer: D
Rationale: Pica is a disorder characterized by the ingestion of nonfood substances, which can lead to a clinical iron deficiency. It may be the first sign of an underlying issue. Individuals with pica consume a variety of nonfood items such as ice, clay, dirt, or paste. Choice A, dependency on alcohol, is incorrect as it is not related to pica. Choice B, increased iron in the diet, is incorrect because pica involves ingesting nonfood items rather than having an increased intake of iron. Choice C, the sickle cell trait, is unrelated to pica and is therefore incorrect.
In alcoholics with anemia:
- A. Pernicious anemia is more common than folic acid deficiency.
- B. Iron deficiency and folic acid deficiency can coexist.
- C. The alcohol interferes with iron absorption.
- D. Oral vitamin replacement is contraindicated.
Correct Answer: B
Rationale: In alcoholics with anemia, iron deficiency and folic acid deficiency can coexist due to poor dietary intake and malabsorption issues associated with chronic alcohol consumption. Pernicious anemia, primarily related to vitamin B12 deficiency, is not commonly seen in alcoholics. While alcohol can interfere with iron absorption, it is not the sole factor contributing to anemia in alcoholics. Oral vitamin replacement is not contraindicated in alcoholics with anemia; however, it may be less effective due to absorption issues related to alcohol consumption.
Which of the following is not a primary function of the kidneys?
- A. blood pressure control
- B. vitamin D activation
- C. erythropoietin production
- D. reabsorption of waste products
Correct Answer: D
Rationale: The correct answer is reabsorption of waste products because the kidneys excrete waste products rather than reabsorbing them. Choices A, B, and C are indeed primary functions of the kidneys. The kidneys play a crucial role in regulating blood pressure, activating vitamin D, and producing erythropoietin, which stimulates red blood cell production. Therefore, the primary role of the kidneys is to filter blood, remove waste products, regulate fluid balance, and maintain electrolyte balance.
Which of the following injuries, presented by a client entering the Emergency Department, is the highest priority?
- A. open leg fracture
- B. open head injury
- C. stab wound to the chest
- D. traumatic amputation of a thumb
Correct Answer: C
Rationale: A stab wound to the chest is the highest priority injury. This type of injury can lead to lung collapse and mediastinal shift, potentially resulting in death if left untreated. Treating an obstructed airway or a chest wound takes precedence over addressing hemorrhage. The principle of ABC (airway, breathing, and circulation) guides care decisions in prioritizing life-threatening situations. An open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate threat to life compared to a stab wound to the chest. An open leg fracture may lead to significant blood loss but is not immediately life-threatening. An open head injury requires assessment and intervention but does not impact airway, breathing, or circulation directly. Traumatic amputation of a thumb is a serious injury but can be managed after addressing more life-threatening conditions.
The client with a history of advanced chronic obstructive pulmonary disease (COPD) had conventional gallbladder surgery 2 days previously. Which intervention has priority for preventing respiratory complications?
- A. Incentive spirometry every 1 to 2 hours.
- B. Coughing and deep breathing every 1 to 2 hours.
- C. Getting the client out of bed 4 times daily as ordered by the physician.
- D. Giving oxygen at 4 L/minute according to the physician's order.
Correct Answer: C
Rationale: The priority intervention for preventing respiratory complications in a client with advanced COPD who underwent gallbladder surgery is to get the client out of bed 4 times daily. This helps prevent pooling of secretions in the lungs and promotes better lung expansion. Incentive spirometry, coughing, and deep breathing are essential interventions; however, they should be performed more frequently, ideally every 1 to 2 hours, rather than every 4 hours or 4 times daily. Giving oxygen at 4 L/minute could potentially decrease the client's respiratory drive, which is not the priority in this case.