Nokea
The nurse instructed a client discharged with crutches on how to use the stairs. Which statement by the client indicates a correct understanding of the teaching?
- A. I should hold the handrail for support with one hand.
- B. When going up the stairs, I should lead with my crutches and weaker leg.
- C. When going down the stairs, I should lead with my crutches and strong leg.
- D. I should remove the rubber tip when going up and down the stairs.
Correct Answer: A
Rationale: Holding the handrail provides stability. Ascending requires leading with the stronger leg, descending with crutches and weaker leg, and rubber tips remain on.
You may also like to solve these questions
The nurse cares for many clients at the end of life who experience symptoms, such as pain, that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association's position on pain management at the end of life?
- A. Advocate for pain management unless life-threatening side effects occur.
- B. Advocate for pain management even if the life-threatening side effects hasten death.
- C. Prohibit the respiratory system from depressing drugs because this is euthanasia.
- D. Allow families to administer respiratory system depressing drugs to hasten death.
Correct Answer: B
Rationale: The ANA supports pain relief at end-of-life, even if side effects like respiratory depression hasten death, prioritizing comfort. Other options misalign with ethical standards.
The nurse prepares a client for a positron emission tomography (PET) scan. Which laboratory data is necessary to obtain before this test?
- A. Urine specific gravity
- B. Liver function tests
- C. Blood glucose
- D. Creatine kinase
Correct Answer: C
Rationale: PET scans often use glucose-based tracers, so blood glucose levels must be checked to ensure accurate imaging. Other labs are not routinely required.
The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Immediately evacuate clients and personnel from the area.
- B. Don personal protective equipment (PPE) before cleaning up the spill.
- C. Contain the spill using non-absorbable sheets or pads.
- D. Complete an incident report.
- E. Discard all material used in cleanup in a trash bag.
- F. Implement droplet precautions after the spill has been cleaned.
Correct Answer: A,B,C,D
Rationale: Evacuation, PPE, containment, and incident reporting are standard for chemotherapy spills. Cleanup materials require biohazard disposal, not regular trash.
A newly licensed registered nurse is tasked by a nurse educator to perform a wet-to-dry dressing change on a client with a stage 3 pressure ulcer. Which action would indicate to the nurse educator that the registered nurse is following proper technique?
- A. The registered nurse cleans the ulcer from the outside, rotating into the inside of the ulcer.
- B. The registered nurse packs the incision with sterile gauze, then pours sterile normal saline over the dressing.
- C. The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin.
- D. The registered nurse saturates the old dressing with sterile saline before removing it.
Correct Answer: C
Rationale: Packing wet gauze into the ulcer without overlapping onto the skin ensures effective debridement without irritating healthy tissue. Other options are incorrect techniques.
The nurse reviews a client’s laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up?
- A. Sodium level
- B. Potassium level
- C. Blood Urea Nitrogen (BUN)
- D. Creatinine
Correct Answer: B
Rationale: Abnormal potassium levels can cause cardiac arrhythmias, a critical risk during surgery, requiring immediate follow-up. Sodium, BUN, and creatinine abnormalities are less immediately life-threatening but still important.