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The nurse is observing an unlicensed assistive personnel (UAP) care for an older client who had surgery (insertion of a prosthesis) following a hip fracture 4 days ago. To prevent client injury, the nurse should intervene in the care when which action is performed by the UAP?
- A. Elevates the head of bed 30 degrees
- B. Assists the client in inserting dentures
- C. Obtains a bedside commode to keep in the room
- D. Places pillows between the legs when turning the client
Correct Answer: C
Rationale: After hip surgery when a prosthesis has been inserted, a client should not flex the body more than 90 degrees relative to the chair; sitting on a commode would mean a low seat. The toilet seat should be raised, so a special adapted commode should be placed in the room. The head of the bed can be raised slightly for comfort. Assisting the client in inserting dentures is within the duties of a UAP. The legs should be kept abducted, so using pillows between the legs when turning is required.
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A 6-year-old child has had heart surgery to repair tetralogy of Fallot. When developing the discharge plan, the nurse should include information about:
- A. Allowing the child to lead a normal, active life.
- B. Persuading the child to get enough rest.
- C. Having the child develop postoperative complications.
- D. Having the child out of school for a month.
Correct Answer: A
Rationale: After tetralogy of Fallot repair, children can often lead a normal, active life with appropriate follow-up.
The client with a burn injury is assessed using the 'rule of nines' to determine which of the following?
- A. Amount of body surface area burned.
- B. Rehabilitation needs.
- C. Respiratory needs.
- D. Type of intravenous fluids required.
Correct Answer: A
Rationale: The rule of nines estimates the percentage of body surface area burned to guide treatment.
A client with a history of chronic lymphocytic leukemia is prescribed prednisone. The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Weight gain.
- C. Hypotension.
- D. Hair loss.
Correct Answer: B
Rationale: Prednisone, a corticosteroid, commonly causes weight gain due to fluid retention and increased appetite.
The nurse is caring for a client who has just undergone a pacemaker insertion. Which of the following instructions should the nurse include in the discharge teaching?
- A. Avoid lifting heavy objects for 4-6 weeks.
- B. Resume driving immediately.
- C. Use a microwave oven without restrictions.
- D. Avoid cell phone use permanently.
Correct Answer: A
Rationale: Avoiding heavy lifting for 4-6 weeks prevents dislodgement of the pacemaker leads during healing.
The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?
- A. Normal sinus rhythm.
- B. Sinus tachycardia.
- C. Ventricular tachycardia.
- D. Ventricular fibrillation.
Correct Answer: C
Rationale: Without the strip, ventricular tachycardia is assumed for its clinical urgency in a test context, requiring immediate intervention.