Nokea
The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?
- A. Place a pillow under the patient's lower legs.
- B. Turn the head toward one side with a large, soft pillow.
- C. Position legs flat against the bed.
- D. Raise the head of the bed to 45 degrees.
Correct Answer: A
Rationale: Placing a pillow under the patient's lower legs when in the prone position is essential to allow dorsiflexion of the ankles and some knee flexion, which promote relaxation. This position also helps in maintaining proper alignment of the spine. Options B, C, and D are incorrect because turning the head, positioning legs flat against the bed, and raising the head of the bed to 45 degrees are not appropriate actions for a patient in the prone position. Turning the head to one side with a large, soft pillow is commonly done for patients in the supine position to maintain proper alignment and airway patency. Positioning legs flat against the bed is more suitable for a patient in a supine or semi-fowler's position. Raising the head of the bed to 45 degrees is typically done for patients who need semi-fowler's positioning for respiratory support or to prevent aspiration.
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When admitting a client with an abdominal wound, which precaution should be taken?
- A. Contact precautions
- B. Droplet precautions
- C. Airborne precautions
- D. Standard precautions
Correct Answer: A
Rationale: When admitting a client with an abdominal wound, contact precautions should be implemented. Contact precautions are used to prevent the spread of infections that are spread by direct or indirect contact. In the case of abdominal wounds, bacteria and pathogens can easily be transmitted through contact with the wound or wound drainage. Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. Airborne precautions are used for infections spread through the air, like tuberculosis. Standard precautions are used for all clients to prevent the spread of infections and should be followed in addition to specific precautions based on the type of infection.
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
- A. Discontinue the machine and measure the blood pressure manually every 15 minutes.
- B. Adjust the machine settings.
- C. Clean the machine to ensure accuracy.
- D. Increase the frequency of the readings.
Correct Answer: B
Rationale: In this scenario, the nurse should adjust the machine settings. If the electronic blood pressure machine is providing varied intervals and inconsistent readings, it indicates a potential malfunction. Changing the settings may help correct the issue and ensure accurate measurements. Discontinuing the machine and measuring manually every 15 minutes (Choice A) may be time-consuming and impractical. Cleaning the machine (Choice C) is important for routine maintenance but may not address the current issue of varied intervals and inconsistent readings. Increasing the frequency of the readings (Choice D) does not address the problem of inaccurate measurements caused by the malfunctioning machine.
A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging?
- A. Slower light touch sensation
- B. Some vision and hearing decline
- C. Slower fine finger movement
- D. Some short-term memory decline
Correct Answer: B
Rationale: As individuals age, it is common to experience changes in vision and hearing, leading to some decline in these senses. Slower light touch sensation and slower fine finger movement are also typical findings associated with aging. However, some short-term memory decline is more closely related to cognitive aging rather than typical age-related changes in the neurologic system. Therefore, the correct answer is the decline in vision and hearing. Decreased risk of depression is not a typical finding in aging; in fact, the risk of depression may increase as individuals age.
A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult?
- A. Becoming actively involved in providing guidance to the next generation.
- B. Adjusting to major changes in roles and relationships due to losses.
- C. Devoting time to establishing an occupation.
- D. Finding oneself 'sandwiched' between and being responsible for two generations.
Correct Answer: C
Rationale: The correct answer is C: Devoting time to establishing an occupation. Young adults typically focus on building their careers and personal identities, making establishing an occupation a crucial developmental task for this age group. Choices A, B, and D do not align with the typical developmental tasks of young adults. Choice A relates more to middle adulthood where individuals take on mentoring roles, choice B is more characteristic of the tasks associated with adjusting to late adulthood, and choice D is more relevant to middle adulthood when individuals may find themselves caring for both their own children and aging parents.
At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, where should the nurse place the stethoscope?
- A. Second intercostal space to the right of the sternum
- B. Fifth intercostal space to the left of the sternum
- C. Third intercostal space to the left of the sternum
- D. Fourth intercostal space at the midclavicular line
Correct Answer: A
Rationale: The correct location to auscultate the aortic valve is the second intercostal space to the right of the sternum. This area corresponds to the aortic valve area where aortic valve sounds are best heard. Choices B, C, and D are incorrect for auscultating the aortic valve. The fifth intercostal space to the left of the sternum is where the mitral valve is best heard, the third intercostal space to the left of the sternum is where the pulmonic valve is best heard, and the fourth intercostal space at the midclavicular line is where the tricuspid valve is best auscultated.