Nokea
The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:
- A. Place the client in a prone position 15-30 minutes twice a day
- B. Keep the foot of the bed elevated on shock blocks
- C. Place trochanter rolls on either side of the affected leg
- D. Keep the client's leg elevated on two pillows
Correct Answer: A
Rationale: Prone positioning helps stretch hip flexors, preventing contractures after AKA by maintaining proper alignment.
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The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has:
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: A pH of 7.47 and PCO2 of 28 indicate respiratory alkalosis, likely due to hyperventilation from the head injury.
The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
- A. Speak using words that rhyme
- B. Repeat words or phrases used by others
- C. Include irrelevant details in conversation
- D. Make up new words with new meanings
Correct Answer: B
Rationale: Echolalia in schizophrenia involves repeating words or phrases spoken by others, reflecting impaired communication processing.
The '5 A's' of smoking cessation intervention begin with which of the following?
- A. Advise all clients who smoke to stop smoking.
- B. Ask all clients about tobacco use at every visit.
- C. Assess clients' willingness to stop smoking.
- D. Assist the client to stop smoking.
Correct Answer: B
Rationale: The 5 A's begin with Ask (B), identifying tobacco use at every visit, followed by Advise, Assess, Assist, and Arrange.
The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- A. The client is at risk for evisceration
- B. The client will require frequent dressing changes
- C. The straps provide support for drains that are inserted into the incision
- D. No sutures or clips are used to secure the incision
Correct Answer: B
Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
- A. Holding the infant
- B. Offering a pacifier
- C. Providing a mobile
- D. Offering sterile water
Correct Answer: B
Rationale: Offering a pacifier is contraindicated after cleft lip repair as it can disrupt the surgical site and impair healing.