Nokea
The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury?
- A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor.
- B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor.
- C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position.
- D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.
Correct Answer: A
Rationale: Using the gait belt to guide the client against the nurse’s leg minimizes injury. Letting go, instructing a side-lying fall, or using a narrow base increases risk.
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The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with contact precautions? Select all that apply.
- A. Hepatitis C
- B. Cryptococcal meningitis
- C. Clostridium difficile
- D. Scabies
- E. Rheumatic fever
- F. Botulism
- G. Hepatitis B
Correct Answer: C,D
Rationale: Clostridium difficile and scabies require contact precautions due to direct or indirect transmission. Others require standard precautions.
One of the complications associated with the improper use of crutches is:
- A. Axillary nerve damage
- B. Solar plexus nerve damage
- C. Carpal tunnel syndrome
- D. Trigeminal nerve damage
Correct Answer: A
Rationale: Improper crutch use can compress the axillary nerve, causing nerve damage. Other options are unrelated to crutches.
The nurse is preparing to administer an enema to a client who is experiencing constipation. Place the following actions in the order listed:
- A. Lubricate the tip of the enema applicator
- B. Remove the applicator after the solution has been infused.
- C. Explain the procedure and help the client lie on the left side with their knees flexed and back toward you
- D. Release clamp
- E. Insert into the client's rectum
- F. Fill the enema bag, prime, and clamp tubing
Correct Answer: F,A,C,E,D,B
Rationale: The correct order is: fill and prime bag (F), explain and position client (C), lubricate tip (A), insert tube (E), release clamp (D), remove applicator (B). This ensures safe administration.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.