Nokea
The nurse is assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning. Which of the following would pose the greatest hazard to the client as a risk for falling at home?
- A. A 4-year-old cocker spaniel.
- B. Scatter rugs.
- C. Snack tables.
- D. Rocking chairs.
Correct Answer: B
Rationale: Scatter rugs are a significant fall risk due to tripping hazards.
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How often should the postoperative client's temperature be assessed during the first 24 hours after surgery?
- A. Every 2 hours.
- B. Every 4 hours.
- C. Every 6 hours.
- D. Every 8 hours.
Correct Answer: B
Rationale: Assessing temperature every 4 hours in the first 24 hours detects fever early, indicating potential infection or other complications.
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
- A. Back at the level of the client's scapula.
- B. Back and head that are high.
- C. Seat that is lower than normal.
- D. Seat with firm cushions.
- E. Chair controlled by client's breath.
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.
A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 38.4°C; pulse 114; respirations 22; blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider for the client to receive:
- A. Hydromorphone (Dilaudid) I.V.
- B. Diltiazem (Cardizem) PO.
- C. Meperidine (Demerol) I.M.
- D. Promethazine (Phenergan).
Correct Answer: A
Rationale: Severe pain requires a potent analgesic. Hydromorphone I.V. (A) provides rapid, effective pain relief. Diltiazem (B) is for cardiac conditions, not pain. Meperidine (C) is less preferred due to side effects, and promethazine (D) is for nausea, not pain.
A client on hemodialysis reports muscle cramps. The nurse should:
- A. Increase dialysate flow.
- B. Check electrolyte levels.
- C. Administer a diuretic.
- D. Encourage ambulation.
Correct Answer: B
Rationale: Muscle cramps may indicate electrolyte imbalances, requiring lab assessment.