Nokea
The nurse is caring for assigned clients. The nurse should first check the client
- A. with hypothyroidism who is reporting constipation, weakness, and peripheral edema
- B. with chronic pancreatitis who is reporting upper abdominal pain and voluminous, foul-smelling, fatty stools
- C. who has bacterial pneumonia, is receiving IV antibiotic therapy, and is reporting a cough productive of blood-tinged sputum
- D. who has an external fixation device, a temperature of 101.8°F (38.8°C), and is reporting redness and pain around the pin sites
Correct Answer: D
Rationale: Fever, redness, and pain around pin sites suggest a possible infection at the external fixation site, which is a priority due to the risk of osteomyelitis or systemic infection.
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A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for reinforcement of teaching?
- A. Faces forward when going up and down the stairs
- B. Holds the cane with the right hand
- C. Leads with left leg, follows next with cane, and finally right leg when going up the stairs
- D. Places full weight on left leg when going down the stairs
Correct Answer: D
Rationale: Placing full weight on the surgical leg when going down stairs risks injury and instability. The client should lead with the cane and unaffected leg, using the surgical leg cautiously.
The nurse is screening clients for those at risk for developing a pressure injury. At highest risk for developing a pressure injury is the client
- A. who had an open cholecystectomy and has a closed-wound drainage device
- B. who has a long leg cast and a decreased serum albumin level
- C. with dementia, peripheral artery disease, and constipation
- D. with quadriplegia, moist skin, and an elevated temperature
Correct Answer: D
Rationale: Clients with quadriplegia are at high risk due to immobility, which impairs circulation and increases pressure on skin. Moist skin increases the risk of skin breakdown, and elevated temperature may indicate infection or inflammation, further increasing risk.
The nurse is caring for a client who is confused and is in soft wrist restraints. Which tasks can the nurse safely assign to unlicensed assistive personnel? Select all that apply.
- A. Assist the client with using a bedpan
- B. Check circulation and sensation of the extremities
- C. Perform range-of-motion exercises
- D. Report changes in skin integrity
- E. Turn and reposition the client in bed
Correct Answer: A,C,D,E
Rationale: UAP can assist with bedpan use (A), perform range-of-motion exercises (C), report skin changes (D), and reposition the client (E). Checking circulation and sensation (B) requires nursing assessment skills.
A child's burn is debrided each day with hydrotherapy to remove the eschar. The child's parents ask why this immersion is necessary. What is the most appropriate response for the nurse to make?
- A. By removing the scab or crusting daily in the special bath, we help prevent infection and then the healthy tissue may be covered by skin grafts.'
- B. By submersion in a whirlpool bath, we can better exercise her limbs to prevent contractures.'
- C. This is a cleansing bath given so that fresh dressings may be applied to the burn areas.'
- D. We decrease her chance of infection by immersion in antibiotic solutions with each debriding bath.'
Correct Answer: A
Rationale: Hydrotherapy removes eschar to prevent infection and prepare for grafting, accurately explaining the procedure's purpose.
The physician has recommended that an adult male be scheduled for a left heart catheterization. The client asks the nurse what a cardiac catheterization is for. What information should be included when responding to this client?
- A. During a left heart catheterization, the coronary arteries can be visualized.
- B. During a left heart catheterization, holes in the heart walls can be detected.
- C. During a left heart catheterization, blood flow to the lungs can be measured.
- D. During a left heart catheterization, oxygen levels in the chambers of the heart are measured.
Correct Answer: A
Rationale: Left heart catheterization visualizes coronary arteries to assess for blockages, aiding in diagnosing coronary artery disease.