Nokea
The nurse is observing a client who sustained a left ankle sprain ascending the stairs using a modified 3-point gait. The nurse should intervene if the client is observed
- A. bearing weight on the right leg
- B. realigning the crutches between each step
- C. assuming the tripod position before ascending the stairs
- D. using the right crutch to support the weight while advancing the left leg onto the next step
Correct Answer: D
Rationale: In a modified 3-point gait, the injured leg (left) should not bear weight, and the right crutch with the left leg should not be used alone to advance. The other actions are consistent with proper crutch use.
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The nurse is reinforcing teaching for a client with heart failure who has had multiple admissions to treat exacerbations. Which of the following statements by the client would require follow-up?
- A. I will begin weighing myself at the same time every day.
- B. I will eat foods high in potassium while taking furosemide.
- C. I will prepare frozen meals at home instead of eating restaurant foods.
- D. I will start incorporating moderate exercise into my daily routine.
Correct Answer: B
Rationale: High-potassium foods can cause hyperkalemia in heart failure patients, especially with certain medications, requiring follow-up. Other statements are appropriate.
A client wanders away from home and is found 48 hours later sleeping on a park bench. The client is awake, alert, and oriented but cannot recall name, address, or events that occurred in the past 2 days. What is the priority nursing action?
- A. Contact family members
- B. Encourage the client to recall recent events
- C. Measure vital signs
- D. Monitor mental status
Correct Answer: C
Rationale: Measuring vital signs is the priority to ensure physiological stability in a client with amnesia, which may indicate a medical emergency like transient global amnesia.
The nurse is caring for a client who has a C6 spinal cord injury. He complains of blurred vision and a severe headache. His blood pressure is 210/140. What action should the nurse take initially?
- A. Check for bladder distention
- B. Place in Trendelenburg position
- C. Administer PRN pain medication
- D. Continue to monitor blood pressure
Correct Answer: A
Rationale: Symptoms and hypertension suggest autonomic dysreflexia, often triggered by bladder distention in spinal cord injury. Checking and relieving distention is the initial action.
A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to
- A. Gently rub the skin with a cotton swab to relieve itching
- B. Place the favorite books and push-pull toys in the crib
- C. Check every few hours for the next day or 2 for swelling in the baby's feet
- D. Turn the baby with the abduction stabilizer bar every 2 hours
Correct Answer: C
Rationale: Check every few hours for the next day or 2 for swelling in the baby's feet. A child in a hip spica cast must be checked for circulatory impairment. The extremities are observed for swelling, discoloration, movement and sensation.
The nurse is reviewing discharge teaching with the parent of a pediatric client who has a new tracheostomy. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. I will immediately change the tracheostomy tube if my child has difficulty breathing
- B. I will provide deep suctioning frequently to prevent any airway obstruction.
- C. I will remove the humidifier if my child develops more secretions.
- D. I will travel with two tracheostomy tubes, one of the same size and one a size smaller.
Correct Answer: D
Rationale: Carrying two tracheostomy tubes (same and smaller size) is correct for emergency preparedness. Immediate tube changes, frequent deep suctioning, or removing humidifiers can worsen the situation or are unsafe.