Nokea
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.
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The purpose of a health assessment is to:
- A. Obtain subjective and objective data
- B. Outline appropriate care
- C. Determine whether interventions are effective
- D. Intervene to correct difficulties
Correct Answer: A
Rationale: Health assessments collect subjective and objective data to inform care planning. Outlining care, evaluating interventions, or correcting issues are subsequent steps.
The nurse is caring for a client with an indwelling urinary catheter connected to a drainage bag. The nurse demonstrates effective care when. Select all that apply.
- A. Emptying the drainage bag when it is half full.
- B. Collecting a urine specimen for culture from the port in drainage tubing.
- C. Clamping the urinary catheter tubing prior to discontinuation.
- D. Instructing the client to carry the collection bag above their bladder during ambulation.
- E. The tubing goes in and out of the urethra during cleaning.
Correct Answer: A,B
Rationale: Emptying when half full prevents reflux, and collecting from the port ensures sterility. Clamping is unnecessary, carrying above the bladder risks reflux, and tubing movement risks infection.
The nurse is teaching a client how to ambulate using a cane. Which action should the nurse take?
- A. Stand on the client's unaffected (stronger) side during ambulation
- B. Instruct the client to look down at their feet as they ambulate
- C. Instruct the client to move the weaker leg to the cane after placing the cane forward.
- D. Advance the cane 6-10 inches with each step
Correct Answer: A
Rationale: Standing on the stronger side provides support. Looking down risks falls, the stronger leg moves first, and advancement is 12-16 inches.
The nurse is caring for a client with right-sided weakness. When transferring the client from the bed to a wheelchair, which action should the nurse perform?
- A. Place the wheelchair as close to the bed as possible on the client's unaffected side
- B. Place the wheelchair as close to the bed as possible on the client's affected side.
- C. Remove any nonskid slippers from the client's feet
- D. Gently pull on the client's arm to assist them to the side of the bed
Correct Answer: A
Rationale: Placing the wheelchair on the unaffected side (left) allows the client to pivot on their stronger side. Affected-side placement, removing slippers, or pulling the arm risk injury or falls.
The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? The student
- A. Applies clean gloves to cleanse the perineal area with soap and water.
- B. Asks the client to bear down as the catheter is slowly inserted through the urethral meatus.
- C. Separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution.
- D. Secures the catheter tubing to the inner thigh.
- E. Attaches the drainage bag to the side rails of bed.
Correct Answer: A,C,E
Rationale: Sterile gloves are required for perineal cleaning, the non-dominant hand holds the labia, and the drainage bag should be attached below the bladder level, not to side rails. Bearing down and securing to the inner thigh are correct.