Nokea
The nurse is instructing the client with a fractured femur in crutch walking. When instructing the client in the best method of manipulating stairs, the nurse should tell the client to:
- A. Start up the stairs with the crutches first.
- B. Start up the stairs with the unaffected leg first.
- C. Use the affected leg to move up the stairs first.
- D. Use the unaffected leg to move down the stairs.
Correct Answer: B
Rationale: For ascending stairs, lead with the unaffected leg to bear weight, followed by crutches and affected leg. This ensures stability and safety.
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Laboratory reference ranges
INR (Therapeutic – atrial fibrillation)
2.0-3.0
The nurse has reinforced teaching for a client with atrial fibrillation who is receiving warfarin. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Antibiotics can affect my INR value.'
- B. I am going to eat more leafy green vegetables.'
- C. I will take the medication at the same time every day.'
- D. I understand that my INR value should be between 4 and 5.'
- E. If I miss a dose of medication, I'll double my dose the next day.'
Correct Answer: A, C
Rationale: Antibiotics affecting INR (A) and consistent timing (C) are correct. More leafy greens (B) can lower INR, INR of 4-5 (D) is too high, and doubling doses (E) is dangerous.
When giving an intramuscular injection to an infant. Which of the following sites is preferred?
- A. Ventrogluteal region
- B. Deltoid
- C. Vastus lateralis
- D. Dorsogluteal region
Correct Answer: C
Rationale: Vastus lateralis is the ideal choice for infants.
The nurse is caring for a client who has congestive heart failure. Which finding indicates that her condition is getting worse?
- A. An increase in urine output
- B. A decrease in blood pressure
- C. A decrease in heart rate
- D. Warm, moist skin
Correct Answer: B
Rationale: A decrease in blood pressure suggests worsening cardiac output in congestive heart failure, indicating decompensation.
The nurse is preparing to obtain a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter that was inserted 2 days ago. Which of the following actions should the nurse take?
- A. Attach a sterile syringe to the specimen port.
- B. Withdraw a sample of fluid from the balloon port.
- C. Empty urine from the urinary drainage bag into a specimen container.
- D. Collect all urine from the urinary drainage bag during a 24-hour period.
Correct Answer: A
Rationale: Using a sterile syringe at the specimen port (A) ensures a clean sample. Balloon port (B), drainage bag (C), or 24-hour collection (D) risk contamination.
The nurse is talking with a client with major depressive disorder who has been taking paroxetine for the past 3 weeks. Which of the following statements by the client would require immediate follow-up?
- A. I have had a decreased appetite lately.'
- B. I still feel depressed even though I have more energy.'
- C. I sometimes have difficulty falling asleep at night.'
- D. I have had a decreased interest in sexual activity recently.'
Correct Answer: B
Rationale: Persistent depression with increased energy (B) may indicate rising suicide risk, requiring immediate follow-up. Appetite (A), sleep (C), and libido (D) changes are common side effects.