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The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do?
- A. Bend at the waist
- B. Keep the feet close together
- C. Pivot on the foot proximal to the chair
- D. Use a transfer belt
Correct Answer: D
Rationale: A transfer belt ensures safety during transfers. Bending at the waist , close feet , and pivoting increase fall risk.
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An 18-month-old child has been placed in Bryant's traction. The nurse knows that the traction is properly applied when:
- A. the affected leg is extended and attached to traction at the foot of the bed.
- B. the legs are at right angles to the child's body and the buttocks are two inches off the bed.
- C. the legs are at right angles to the child's body and the nurse can just put his/her fingers underneath the child's buttocks.
- D. the affected leg is extended and attached to traction at the foot of the bed and there is a vertical pull at the popliteal area.
Correct Answer: C
Rationale: Bryant's traction for infants involves both legs at 90 degrees to the body, with buttocks slightly off the bed (fingers can fit underneath), ensuring proper alignment and traction force.
The nurse is caring for a client who has been started on sulfamethoxazole/trimethoprim for a urinary tract infection. It is most important for the nurse to follow up on which client statement?
- A. I go to the bathroom a lot more than usual
- B. It burns when I pee.
- C. My urine is cloudy
- D. There is a red rash on my abdomen.
Correct Answer: D
Rationale: A rash may indicate an allergic reaction, requiring urgent follow-up. Frequent urination , burning , and cloudy urine are UTI symptoms.
A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply.
- A. Chronic hypoxemia
- B. Diabetes insipidus
- C. Frequent respiratory infections
- D. Obesity
- E. Vitamin deficiencies
Correct Answer: A,C,E
Rationale: Cystic fibrosis causes chronic hypoxemia , frequent infections , and vitamin deficiencies due to malabsorption. Diabetes insipidus is unrelated, and obesity is unlikely due to high metabolic demand.
The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, HPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying?
- A. DTaP
- B. Hepatitis B
- C. Polio
- D. H. Influenza
Correct Answer: A
Rationale: The majority of reactions occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization.
Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
- A. Venturi mask
- B. Partial rebreather mask
- C. Non-rebreather mask
- D. Simple face mask
Correct Answer: C
Rationale: Non-rebreather mask. The non-rebreather mask has a one-way valve that prevents exhaled air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of the oxygen is available.