Nokea
The nurse is assisting a client to adjust crutches to the proper measurement. With the client in standing position, where should the tips of the crutches be placed?
- A. 2 to 3 inches directly to the side of the client's legs
- B. 4 to 6 inches to the side of the client's legs and 4 to 6 inches in front of feet
- C. 2 to 3 inches to the side of the client's legs and 4 to 6 inches in front of feet
- D. 4 to 6 inches directly to the side of the client's legs
Correct Answer: B
Rationale: Crutch tips should be 4-6 inches to the side and 4-6 inches in front of the feet (B) for stability and balance.
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A client is scheduled for a colposcopy. The nurse assists the client into which position?
- A. Sim's position
- B. supine position, with the head of the bed elevated 15 degrees
- C. left-side-lying position, knees to chest
- D. lithotomy position
Correct Answer: D
Rationale: Colposcopy requires the lithotomy position to provide access to the cervix for examination.
The nurse is assessing a client with suspected dehydration. Which of the following findings would the nurse expect?
- A. Bradycardia and hypertension.
- B. Dry mucous membranes and tented skin.
- C. Clear, dilute urine.
- D. Increased respiratory rate.
Correct Answer: B
Rationale: dry mucous membranes and tented skin are signs of dehydration due to fluid loss
To ensure safety while administering a nitroglycerine patch, the nurse should:
- A. Wear gloves while applying the patch.
- B. Shave the area where the patch will be applied.
- C. Wash the area thoroughly with soap and rinse with hot water.
- D. Apply the patch to the buttocks.
Correct Answer: A
Rationale: Gloves prevent the nurse from absorbing nitroglycerin, avoiding side effects.
How many hours of activity per day are necessary to prevent disuse syndrome with muscle atrophy and joint contracture?
- A. 6 hours
- B. 4 hours
- C. 2 hours
- D. 1 hour
Correct Answer: C
Rationale: Approximately 2 hours of activity daily (C), including range-of-motion exercises or ambulation, helps prevent disuse syndrome, muscle atrophy, and joint contractures in immobilized clients.
Which of the following roommates would be best for the client newly admitted with gastric resection?
- A. A client with Crohn's disease
- B. A client with pneumonia
- C. A client with gastritis
- D. A client with phlebitis
Correct Answer: C
Rationale: Gastritis aligns with gastric resection, posing no infection risk.