Nokea
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
- A. Assist the client into a prone position.
- B. Place a sleeve over the top of each leg with the opening at the knee.
- C. Make sure two fingers can fit under the sleeves.
- D. Set the ankle pressure at 65 mm Hg.
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This action ensures proper fit and compression without causing restriction or compromising circulation. A: Assisting the client into a prone position is not necessary for applying the sleeves. B: Placing the sleeve with the opening at the knee is incorrect as it should be at the top of the leg. D: Setting the ankle pressure at 65 mm Hg is not specified for thigh-length sleeves and may not be appropriate.
You may also like to solve these questions
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
- A. Use the Face Legs Activity Cry and Consolability (FLACC) pain rating scale for a client who is experiencing pain.
- B. Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm.
- C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum.
- D. Palpate the client's abdomen before auscultating bowel sounds.
Correct Answer: B
Rationale: The correct answer is B: Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm. This is the correct physical assessment technique because proper cuff placement is essential for accurate blood pressure measurement. Placing the cuff around 50% of the arm circumference ensures that the blood pressure reading is not falsely elevated or decreased. Incorrect choices: A: Using the FLACC pain rating scale is relevant for pain assessment, but not a physical assessment technique. C: Obtaining an apical heart rate by auscultating at the third intercostal space left of the sternum is incorrect as the fifth intercostal space at the midclavicular line is the correct location. D: Palpating the client's abdomen before auscultating bowel sounds is incorrect as bowel sounds should be auscultated first to prevent stimulating peristalsis.
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
- A. Weak pulses with +2 dependent edema in lower extremities.
- B. Slightly labored respirations at rest.
- C. Wheezes and crackles in the chest.
- D. Reports productive cough during the overnight hours.
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client's refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The nurse's priority is to assess why the client is refusing the treatment to address the underlying issue. By understanding the client's reasoning, the nurse can provide appropriate interventions and education to encourage compliance, ensuring optimal recovery. Requesting a respiratory therapist (A) may be helpful but does not address the client's refusal directly. Documenting the refusal (C) is important but does not actively address the issue. Administering pain medication (D) may provide temporary relief but doesn't address the root cause of refusal.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief.
- D. Reassure the client that this is an expected response to grief.
Correct Answer: C
Rationale: The correct answer is C: Provide the client with written information about the phases of loss and grief. This is the most appropriate action as the client is expressing anger, which is a normal part of the grieving process. By providing information about the phases of loss and grief, the nurse can help the client understand his emotions and cope with them effectively.
A: Discussing risk factors for colon cancer is not the immediate priority when the client is expressing anger.
B: Focusing on future management may be overwhelming for the client at this stage when he is dealing with emotional distress.
D: Reassuring the client that his response is expected is helpful, but providing information on coping mechanisms is more beneficial in this situation.
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
- A. I can place an extension cord across my living room to plug in my television.
- B. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
- C. I will place my alarm clock on my bedroom dresser across the room.
- D. I will replace the old throw rug in my kitchen with a new one.
Correct Answer: B
Rationale: Correct Answer: B - "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
Rationale: This statement demonstrates understanding as it shows awareness of potential hazards (low-hanging tree) that could obstruct safe walker use. By hiring someone to trim the tree, the client is proactively ensuring a safe environment for mobility with the walker.
Summary of Incorrect Choices:
A: Placing an extension cord across the living room poses a tripping hazard, which is unsafe for walker use.
C: Placing the alarm clock on the bedroom dresser is unrelated to walker safety.
D: Replacing the throw rug in the kitchen is beneficial but not directly related to walker safety.