Nokea
The nurse is observing a client who had a left total knee replacement using a cane to descend stairs. It would demonstrate correct technique if the client descends the stairs by placing the
- A. cane on the step first, followed by the affected leg, and then the unaffected leg
- B. cane on the step first, followed by the unaffected leg, and then the affected leg
- C. affected leg on the step first, followed by the cane, and then the unaffected leg
- D. unaffected leg on the step first, followed by the affected leg, and then the cane
Correct Answer: A
Rationale: For descending stairs, the cane and affected leg move together after the unaffected leg, providing stability.
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Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? Select all that apply.
- A. The nurse accepts money from the victim
- B. The nurse does not accompany the victim on the ambulance
- C. The nurse does not apply direct pressure to the artery
- D. The nurse knows the victim from college
- E. The victim dies after reaching the hospital
Correct Answer: A,C
Rationale: Accepting money negates Good Samaritan protection, and failure to apply direct pressure could be considered negligent care.
The nurse is teaching the parent of a 6-year-old client about sleep. Which of the following information should the nurse include? Select all that apply.
- A. Your child should sleep 9 to 12 hours every night.
- B. As your child grows, the hours of required sleep increase.
- C. Encourage active play before bedtime to promote restful sleep.
- D. Avoid giving your child large amounts of liquid after dinnertime.
- E. It is important to establish and maintain a regular bedtime routine.
Correct Answer: A,D,E
Rationale: Children aged 6 need 9-11 hours of sleep, limited liquids prevent bedwetting, and routines promote sleep. Sleep needs decrease with age, and active play close to bedtime may disrupt sleep.
The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?
- A. Provide small feedings every 3 hours
- B. Maintain intravenous fluids
- C. Add strained cereal to the diet
- D. Change to reduced calorie formula
Correct Answer: A
Rationale: Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.
The nurse is reinforcing teaching with a client who had a total knee replacement and has a new prescription for enoxaparin. Which of the following information should the nurse reinforce?
- A. Mild bruising or redness may occur at the injection site.
- B. Eliminate green, leafy, vitamin K-rich vegetables from your diet.
- C. Black stools are a common, harmless adverse effect of the medication.
- D. Take over-the-counter medications such as ibuprofen to relieve mild discomfort.
Correct Answer: A
Rationale: Mild bruising or redness is an expected side effect of enoxaparin. Black stools indicate possible bleeding, and ibuprofen increases bleeding risk. Vitamin K restriction is not necessary.
A nurse has administered several blood transfusions over 3 days to a 12 year-old client with Thalassemia. What lab value should the nurse monitor closely during this therapy?
- A. Hemoglobin
- B. Red Blood Cell Indices
- C. Platelet count
- D. Neutrophil percent
Correct Answer: A
Rationale: Hemoglobin should be in a therapeutic range of approximately 10 g/dl (100 g). This level is low enough to foster the patient’s own erythropoiesis without enlarging the spleen.