Nokea
The nurse is caring for the newly admitted male client who is unconscious. The UAP asks if the client should be shaved. What is the nurse's best response?
- A. I need to find out the client's preferences first.
- B. Shave him only after you have bathed him.
- C. Use the electric razor when you shave him.
- D. Avoid shaving him. I need a doctor's order.
Correct Answer: A
Rationale: A: Removal of facial hair varies based on personal and cultural preferences, which should be assessed first. B: Bathing order is irrelevant without preferences. C: Electric razors are safe but preferences are unknown. D: Shaving does not require a doctor's order.
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A standard walker is used when clients:
- A. have poor balance, cannot stand up, have weak arms, and have good hand strength.
- B. have poor balance, have a broken leg, or have experienced amputation.
- C. have poor balance, have cardiac problems, or cannot use crutches or a cane.
- D. have poor balance, have an autoimmune disease, or have weak arms.
Correct Answer: C
Rationale: A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward.
While repositioning the client, the LPN notices a shallow, open ulcer on the sacrum with partial-thickness skin loss. What is the classification stage of this ulcer?
- A. Stage I
- B. Stage IV
- C. Stage II
- D. Stage III
Correct Answer: C
Rationale: An ulcer is classified as stage II when the skin is not intact and there is partial-thickness skin loss. An ulcer with full-thickness skin loss would be stage III.
The client began wearing hearing aids 5 weeks earlier. Which statement to the nurse demonstrates that the client is successfully adapting to the hearing aids?
- A. I need to wear the hearing aids only when I go out in public.
- B. I clean my ears with a cotton-tipped swab before I insert them.
- C. I place the hearing aids in the protective box to store them at night.
- D. I soak the plastic parts of the hearing aids in mild soap and water weekly.
Correct Answer: C
Rationale: C: Hearing aids are expensive and delicate, and they should be stored in a protective container in a dry, safe place. A: Hearing aids should be worn daily to adjust to their use. B: Cotton-tipped swabs should not be inserted into the ear canal due to possible injury and infection. D: Hearing aids should be kept dry except when cleaning the ear mold with mild soap and water.
The nurse is evaluating the client's ability to perform active ROM. Which illustration demonstrates the client's ability to correctly perform eversion?
- A. eversion_1.PNG
- B. eversion_2.PNG
- C. eversion_3.PNG
- D. eversion_4.PNG
Correct Answer: C
Rationale: C: Eversion is turning the foot outward. A: Shows external rotation. B: Shows internal rotation. D: Shows inversion.
The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?
- A. The student should not be touching the plaster cast because it is wet.
- B. The student should be using a pillow to lift the client's casted extremity.
- C. The student is correctly handling a wet plaster cast with the palms.
- D. The student should be using fingers and not the palms to handle the cast.
Correct Answer: C
Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.