Nokea
The nurse is caring for a client who is 24 hours postoperative following a left total knee replacement. Which assessment data would indicate that the client is ready for discharge?
- A. Pulse (P) 102, RR 18, BP 104/72 mm Hg
- B. Urine output of 200 mL in the past 8 hours
- C. Lung bases are clear upon auscultation
- D. The client rates left knee pain as 8/10 on the Numerical Rating Scale
Correct Answer: C
Rationale: Clear lung bases indicate no respiratory complications, such as pneumonia, which is critical for discharge readiness. A pulse of 102 and low blood pressure (104/72 mm Hg) suggest possible instability, requiring further evaluation. Low urine output (200 mL/8 hours) indicates potential renal issues, and severe pain (8/10) suggests inadequate pain control, both contraindicating discharge.
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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.
The nurse is discussing negligence with a new nurse. Which of the following situations can the nurse use as an example of negligence?
- A. The Unlicensed Assistive Personnel (UAP) fills a water basin with warm water while the client with depression combs their hair.
- B. A nurse transcribes a new medication order: Cholestyramine powder 2 oz bid with wet food or one full glass of water.
- C. The nurse first checks the distal pulses of a client's legs two hours after they have returned from a cardiac catheterization.
- D. The nurse observes a UAP enter the room of a client on contact precautions wearing gloves and a gown.
Correct Answer: NONE
Rationale: None of the options describe negligence, as all reflect appropriate actions or minor procedural variations without harm.
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.
The nurse is caring for a client with the following clinical data. Based on the clinical data, the nurse should clarify which order with the primary healthcare provider (PHCP)
- A. Urine analysis (UA)
- B. Head CT Scan
- C. Regular diet
- D. Ammonia level
Correct Answer: C
Rationale: A regular diet prescription should be questioned because of the client's medical history of diabetes mellitus and hypertension. The appropriate diet would be one restricted in carbohydrates and sodium. Thus, the nurse should follow up with the PHCP regarding this order.
Ergonomic principles are most closely associated with:
- A. Normal bodily alignment
- B. The control of infection
- C. Preventing congenital abnormalities
- D. Preventing hospital-acquired infections
Correct Answer: A
Rationale: Ergonomics focuses on optimizing bodily alignment to reduce strain. Infection control and congenital abnormalities are unrelated.