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The nurse is discussing positioning with the family of a client who is at home following a total hip replacement a week ago. Which should be included in the discussion?
- A. Keep the client on his unaffected side most of the time.
- B. Position the client to maintain hip flexion.
- C. Keep a pillow between his legs when turning him.
- D. Position the client so the hip is adducted.
Correct Answer: C
Rationale: A pillow between the legs maintains hip abduction, preventing dislocation post-hip replacement, a critical positioning instruction.
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The nurse is caring for a client with tuberculosis who is on airborne isolation precautions. The nurse can delegate which tasks to experienced unlicensed assistive personnel? Select all that apply.
- A. Alert the x-ray department about maintaining airborne isolation precautions
- B. Explain to the client why the client must wear a mask during transport to another department
- C. Post signs for airborne isolation precautions on the client's door and stock necessary equipment
- D. Remind visitors to wear a respirator mask and keep the door closed while in the client's room
- E. Talk with the family about the reasons for airborne isolation precautions in the client
Correct Answer: C, D
Rationale: Posting signs and stocking equipment (C) and reminding visitors about precautions (D) are within UAP scope. Alerting departments (A), explaining to the client (B), and educating family (E) require nursing judgment.
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
- A. Place pillows under the knees
- B. Use elastic stockings continuously
- C. Encourage range of motion and ambulation
- D. Massage the legs twice daily
Correct Answer: C
Rationale: Encourage range of motion and ambulation. Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk due to other factors.
A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?
- A. Diffuse expiratory wheezing
- B. Loose, productive cough
- C. No relief from inhalant
- D. Fever and chills
Correct Answer: A
Rationale: In asthma, the airways are narrowed, creating difficulty getting air in. A wheezing sound results.
The nurse caring for a client scheduled for an angiogram should prepare the client for the procedure by telling him to expect:
- A. Dizziness as the dye is injected.
- B. Nausea and vomiting after the procedure is completed.
- C. A decreased heart rate for several hours after the procedure is completed.
- D. A warm sensation as the dye is injected.
Correct Answer: D
Rationale: A warm sensation is common during dye injection in an angiogram. Dizziness , nausea , and decreased heart rate are not typical.
The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply.
- A. Depressed anterior fontanelle
- B. High-pitched cry
- C. Poor feeding
- D. Presence of the Babinski sign
- E. Vomiting
Correct Answer: B, C, E
Rationale: High-pitched cry (B), poor feeding (C), and vomiting (E) are signs of bacterial meningitis in infants. A depressed fontanelle (A) suggests dehydration, not meningitis, and Babinski sign (D) is normal in infants.