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The nurse is observing the UAP providing oral hygiene to the client Which action by the UAP requires follow-up?
- A. Replacing the upper denture before the lower denture.
- B. Placing the unconscious client in a supine position.
- C. Brushing the tongue with a soft-bristled toothbrush.
- D. Donning clean gloves prior to performing oral hygiene.
Correct Answer: B
Rationale: B: The unconscious client should be placed in a side-lying position with the head turned to the side to prevent aspiration. A: Replacing the upper denture first is correct for ease of insertion. C: Brushing the tongue removes debris, reducing infection risk. D: Gloves adhere to standard precautions for oral care.
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The client who has bilateral hand burns reports wearing soft contact lenses that need to be removed. Which action(s) are important for the nurse to include in this procedure? Select all that apply.
- A. Perform hand hygiene and don gloves.
- B. Pinch the lens over the pupil and remove.
- C. Place the lens in a sterile container with normal saline.
- D. Irrigate the eye with normal saline to loosen the lens.
- E. Instruct the client to look up when removing the lens.
Correct Answer: A,C,E
Rationale: A: Hand hygiene and gloves prevent infection. C: Normal saline keeps lenses moist if no lens solution is available. E: Looking up aids safe lens removal. B: Pinching over the pupil risks corneal abrasion. D: Irrigation could damage or lose the lens.
The nurse is turning a client who has a new prosthetic hip. Which position should be avoided to prevent injury to the new prosthetic hip?
- A. abduction of the hip
- B. adduction of the hip
- C. flexing the hip at 80° flexion
- D. flexing the hip at 90°
Correct Answer: B
Rationale: New prosthetic hips should have an abduction pillow in place to avoid adduction.
According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to:
- A. clients (patients)
- B. the profession of nursing
- C. provide high-quality care
- D. all of the above
Correct Answer: D
Rationale: The ANA Code of Ethics encompasses obligations to clients, the nursing profession, and delivering high-quality care, ensuring comprehensive ethical practice.
A client is having problems with her ankles. To assess her ankles' ROM, which ROM exercises should the nurse have her perform?
- A. flexion, extension, hyperextension
- B. flexion, extension, abduction, adduction
- C. external rotation, internal rotation
- D. extension, flexion, inversion, eversion
Correct Answer: D
Rationale: Ankle range of motion includes extension, flexion, inversion, and eversion, assessing the joint's full functional capacity.
A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?
- A. calcium
- B. magnesium
- C. potassium
- D. sodium chloride
Correct Answer: D
Rationale: Duodenal intestinal fluid is rich in K+, Na+, and bicarbonate. Suctioning to remove excess fluids decreases the client's K+ and Na+ levels.