The nurse is caring for a client immediately following hypop...

The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client

A. Trendelenburg
B. Side-lying
C. high-Fowler's
D. Reverse Trendelenburg

Correct Answer: C

Rationale: High-Fowler’s position (head elevated 30–45 degrees) is recommended post-hypophysectomy to reduce intracranial pressure and prevent cerebrospinal fluid leakage. Trendelenburg and reverse Trendelenburg could increase pressure or disrupt surgical site healing, and side-lying is less effective for this purpose.

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The nurse performs a head-to-toe assessment on an assigned client. Which of the following client findings are examples of subjective data? Select all that apply.

A. The client reports feeling nauseated.
B. The client's lower extremities are swollen.
C. The client expresses nervousness about test results.
D. The client reports that their leg is itching.
E. The client rates pain at a 6 on a scale of 1 to 10.
F. The client vomits twice after eating dinner.

Correct Answer: A,C,D,E

Rationale: Subjective data are client-reported, like nausea, nervousness, itching, and pain rating. Swelling and vomiting are objective, observed by the nurse.

The nurse is teaching a group of unlicensed assistive personnel (UAPs) concepts of client identification. Which situation would require two client identifiers? Select all that apply.

A. Providing a meal tray
B. Changing bed linens
C. Replacing a suction canister
D. Obtaining vital signs
E. Providing range of motion exercises

Correct Answer: C,D

Rationale: Two client identifiers are required for procedures that involve direct client intervention with potential for error, such as replacing a suction canister (invasive equipment) and obtaining vital signs (recorded in medical records). Providing a meal tray, changing bed linens, and range of motion exercises do not typically require two identifiers.

The nurse is caring for a client newly admitted to the medical-surgical unit. Which clinical data is most helpful in assessing the client's fall risk?

A. observing the client's gait and balance
B. the client's ability to turn from side to side while in bed
C. interviewing close family members about the client's gait and balance
D. the client's self-report on their gait and balance

Correct Answer: A

Rationale: Direct observation of gait and balance provides the most reliable data for assessing fall risk.

The nurse is educating staff on infection control. Which of the following statements by the nurse would indicate a correct understanding of infection control guidelines for influenza? Select all that apply.

A. Limiting visitation to 30 minutes per day.
B. Keeping the door to the client's room closed.
C. Wearing a surgical mask when providing care.
D. Placing the client in a room at the end of the hall.
E. Cleaning common surfaces with 70% isopropyl alcohol.

Correct Answer: B,C

Rationale: Influenza requires droplet precautions, including a surgical mask within 3 feet and a closed door to reduce transmission. The other options are not standard for influenza.

The nurse performs a home safety survey for an older adult. Click to specify the findings that require intervention by the nurse.

A. Scatter rugs at the end of the stairs
B. Smoke detector present without a battery
C. Stairs present with sturdy hand rails
D. New light fixtures installed and connected in a grounded electrical outlet
E. Extension cord covered with an anti-skid area rug
F. Unlabeled household chemicals under the sink
G. Fire extinguisher present 30 feet from the stove

Correct Answer: A,B,E

Rationale: Scatter rugs and extension cords pose trip hazards, and a non-functional smoke detector is a fire risk. Unlabeled chemicals risk poisoning, requiring intervention.