Nokea
The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
- A. Raise the head of the bed at least 30 degrees
- B. Encourage ambulation within 24 hours
- C. Maintain in a flat position, logrolling as needed
- D. Encourage leg contraction and relaxation after 48 hours
Correct Answer: C
Rationale: Maintain in a flat position, logrolling as needed. The bed should remain flat for at least the first 24 hours to prevent injury.
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A diet rich in calcium over a lifetime will decrease the risk of
Heart disease
- A. Osteoporosis
- B. Gout
- C. Rheumatoid Arthritis
Correct Answer: B
Rationale: A diet rich in calcium over a lifetime will decrease the risk of osteoporosis by strengthening bones.
A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to the
- A. Yang, the positive force that represents light, warmth, and fullness
- B. Yin, the negative force that represents darkness, cold, and emptiness
- C. Use of improper hot foods, herbs and plants
- D. A failure to keep life in balance with nature and others
Correct Answer: B
Rationale: Yin, the negative force that represents darkness, cold, and emptiness. Excessive Yin is believed to cause illness in Chinese folk medicine.
A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention?
- A. Capillary refill of fingers on right hand is 3 seconds
- B. Skin warm to touch and normally colored
- C. Client reports prickling sensation in the right hand
- D. Slight swelling of fingers of right hand
Correct Answer: C
Rationale: Client reports prickling sensation in the right hand. A prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.
The nurse on the floor will perform peripheral IV site insertion.
Her performance is based on:
- A. Hospital policies and procedures.
- B. Nursing Standards of Practice.
- C. Doctor's orders.
- D. IV regulation developed by the Board of Nursing
Correct Answer: B
Rationale: Nursing Standards of Practice guide safe and competent IV insertion.
A 35-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate.
Which of the following would you most likely suspect?
- A. Atherosclerosis
- B. Diabetic neuropathy
- C. Autonomic neuropathy
- D. Somatic neuropathy
Correct Answer: C
Rationale: Autonomic neuropathy can impair bladder function, causing urinary retention in long-term diabetes.