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The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?
- A. The application of moist heat will alter tissue sensitivity by producing numbness.
- B. The application of moist heat will decrease the metabolic needs of the involved tissues.
- C. The application of moist heat will stop the local release of histamine in the tissues.
- D. The application of moist heat will increase blood flow and accelerate tissue healing.
Correct Answer: D
Rationale: D: Warm compresses increase blood flow, promoting healing. A: Cold causes numbness. B: Heat increases metabolic needs. C: Cold reduces histamine release.
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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.
A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:
- A. sprain.
- B. strain.
- C. subluxation.
- D. distoration.
Correct Answer: B
Rationale: A strain is excessive stretching of a ligament. A sprain involves a twisting motion involving muscles.
Pulling is easier than pushing. So pulling a client rather than pushing him or her has which of the following advantages?
- A. Reduces workload
- B. Decreases opposition from gravity
- C. Maintains stability
- D. Prevents muscle strain
Correct Answer: A
Rationale: Pulling reduces workload by working with gravity, lowering the effort needed compared to pushing against it.
The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these would be an appropriate action taken by the nurse?
- A. Inform the client that ear pain may occur and is normal.
- B. Provide ice water and a straw to promote easy fluid consumption.
- C. Provide hot tea to soothe the throat.
- D. Monitor vitals every 15 minutes.
Correct Answer: A
Rationale: Referred pain in the ear is normal after a tonsillectomy because of related nerve pathways. Vitals should be monitored every 15 minutes in the immediate postoperative period and then every 4 hours thereafter. Straws and hot beverages should be avoided as they may irritate the throat and disturb healing.
The dietitian prescribes a 24-hour calorie count for the malnourished hospitalized client. Which action should be taken by the nurse?
- A. Ask the client to recall at the end of the day the food and beverages consumed.
- B. Inform the client how to count the calories in the food and beverages consumed.
- C. Inform the client that a record will be maintained of food and beverages consumed.
- D. Ask the client to identify the food groups and foods that are being consumed in each.
Correct Answer: C
Rationale: C: Recording food intake ensures accurate calorie counts. A: Recall is unreliable. B: Clients don't calculate calories in hospital. D: Food groups don't provide calorie data.