Nokea
The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching?
- A. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth.
- B. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion.
- C. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume.
- D. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.
Correct Answer: D
Rationale: Getting out of bed upright risks hip dislocation post-hip replacement; log-rolling is correct. Diaphragmatic breathing, foot exercises, and spirometry are appropriate.
You may also like to solve these questions
Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the female client experiencing acute pain?
- A. Take the pain medication to the room.
- B. Apply an ice pack to the site of pain.
- C. Check on the client 30 minutes after she takes the pain medication.
- D. Observe the client's ability to use the PCA.
Correct Answer: B
Rationale: Applying an ice pack is a non-invasive task within UAP scope. Delivering medication, post-medication checks, and PCA observation require nursing judgment.
The unlicensed assistive personnel (UAP) can be overheard talking loudly to the scrub technologist discussing a problem which occurred during one (1) of the surgeries. Which intervention should the nurse in the surgical holding area with a female client implement?
- A. Close the curtains around the client's stretcher.
- B. Instruct the UAP and scrub tech to stop the discussion.
- C. Tell the surgeon on the case what the nurse overheard.
- D. Inform the client the discussion was not about her surgeon.
Correct Answer: B
Rationale: Instructing the UAP and tech to stop protects patient privacy and reduces anxiety, per HIPAA. Curtains, informing the surgeon, or reassuring the client are less direct.
The nurse received a report the elderly postoperative client became confused during the previous shift. Which client problem would the nurse include in the plan of care?
- A. Risk for injury.
- B. Altered comfort level.
- C. Impaired circulation.
- D. Impaired skin integrity.
Correct Answer: A
Rationale: Confusion increases fall and injury risk, the priority problem in elderly postoperative clients. Comfort, circulation, and skin integrity are secondary.
Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Complete the preoperative checklist.
- B. Assess the client's preoperative vital signs.
- C. Teach the client about coughing and deep breathing.
- D. Assist the client to remove clothing and jewelry.
Correct Answer: D
Rationale: Removing clothing and jewelry is a non-invasive task within UAP scope. Checklist completion, vital signs, and teaching require nursing judgment.
The nurse is conducting an interview with a 75-year-old client admitted with acute pain. Which question would have priority when assisting with pain management?
- A. Have you ever had difficulty getting your pain controlled?
- B. What types of surgery have you had in the last 10 years?
- C. Have you ever been addicted to narcotics?
- D. Do you have a list of your prescription medications?
Correct Answer: A
Rationale: Asking about past pain control identifies effective strategies or barriers, guiding management. Surgical history, addiction, and medication lists are secondary.