Nokea
The nurse is caring for a client who is postoperative day 1 following a total hip replacement. Which of the following positions should the nurse AVOID placing the client in?
- A. Supine with legs abducted.
- B. High Fowler’s with legs extended.
- C. Side-lying on the unaffected side.
- D. Prone with legs adducted.
Correct Answer: D
Rationale: prone position with legs adducted can cause hip dislocation; abduction is maintained post-hip replacement
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A student nurse is assigned to change a patient's dressing. The soiled bandage is saturated with bright red blood. How should the student nurse dispose of the bandage?
- A. in the hallway sharps container
- B. in a labeled or color-coded biohazard bag
- C. in the trash, but it must be double bagged
- D. in the trash can in the patient's room
Correct Answer: B
Rationale: Blood-saturated bandages are biohazardous and must be disposed of in a labeled biohazard bag to prevent infection transmission.
Which person is at greatest risk for developing Lyme's disease?
- A. Computer programmer
- B. Elementary teacher
- C. Veterinarian
- D. Landscaper
Correct Answer: D
Rationale: Landscapers are at higher risk for Lyme disease due to frequent exposure to tick-infested outdoor environments, where the disease is transmitted.
The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?
- A. I will apply a petroleum gauze to the area with each diaper change.
- B. I will clean the area carefully with each diaper change.
- C. I can place a heat lamp to the area to speed up the healing process.
- D. I should carefully observe the area for signs of infection.
Correct Answer: C
Rationale: Using a heat lamp is incorrect and could cause burns or delay healing; the other statements reflect appropriate circumcision care.
The ED nurse is caring for a client whose native tongue is not English. The client speaks Korean and only understands a few words of English. The nurse understands that which response is best regarding how to communicate with this client?
- A. ask a bilingual family member to tell the client to point to where the pain is
- B. call the oncology unit and ask for the nurse who is a native Korean to come and translate
- C. show the client the equipment before using it, such as indicating that an IV line will be placed in the arm
- D. call for an official Korean interpreter on the facility's translator hotline to communicate with the client, family, and health care provider
Correct Answer: D
Rationale: Using an official interpreter ensures accurate, unbiased communication, adhering to ethical and legal standards for patient care.
The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?
- A. Order a chest x-ray
- B. Reinsert the tube
- C. Cover the insertion site with a Vaseline gauze
- D. Call the doctor
Correct Answer: C
Rationale: Covering the insertion site with Vaseline gauze prevents air entry into the pleural space, stabilizing the client until further intervention.