Nokea
The nurse is planning care for a client who must remain in bed for several weeks. Which action will do most to prevent the development of pressure ulcers?
- A. Performing range-of-motion exercises
- B. Deep breathing and coughing
- C. Keeping the feet against a footboard
- D. Changing position in bed frequently
Correct Answer: D
Rationale: Frequent position changes relieve pressure on bony prominences, preventing pressure ulcers. ROM, breathing, or footboards address other complications.
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An adult who has cholecystitis reports clay-colored stools and moderate jaundice. The nurse knows that which is the best explanation for the presence of clay-colored stools and jaundice?
- A. There is an obstruction in the pancreatic duct.
- B. There are gallstones in the gallbladder.
- C. Bile is no longer produced by the gallbladder.
- D. There is an obstruction in the common bile duct.
Correct Answer: D
Rationale: Clay-colored stools and jaundice result from a common bile duct obstruction, preventing bile flow to the intestines and causing bilirubin buildup in the blood. The gallbladder stores, not produces, bile, and pancreatic or gallbladder issues are less directly related.
A nurse prepared the 9:00 A.M. medications for his clients and then was called off the unit briefly before he was able to administer them. Who may administer the medications to the clients now?
- A. Any licensed nurse assigned to the unit and familiar with the clients
- B. A pharmacy technician certified to administer medications
- C. The nurse who prepared them
- D. The nurse manager of the unit
Correct Answer: C
Rationale: The nurse who prepared the medications must administer them to ensure accountability and familiarity with the preparation.
To maintain Bryant's traction, the nurse must make certain that the child's:
- A. Hips are resting on the bed with the legs suspended at a right angle to the bed
- B. Hips are slightly elevated above the bed with the legs suspended at a right angle to the bed
- C. Hips are elevated above the level of the body on a pillow with the legs suspended parallel to the bed
- D. Hips and legs are flat on the bed with the traction positioned at the foot of the bed
Correct Answer: B
Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to align the femur properly and reduce pressure on the pelvis.
A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to
- A. maintain fluid and electrolyte balance
- B. manage post-operative pain
- C. ambulate the client within 1 hour of surgery
- D. control bladder spasms
Correct Answer: B
Rationale: Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery.
All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which duties are appropriate for the licensed practical nurse to delegate to unlicensed assistive personnel to promote client safety? Select all that apply.
- A. Educate newly admitted client on the importance of using the call light for assistance
- B. Place the bedside commode as close to the bed as possible
- C. Remind client to change position slowly
- D. Report observations of changes in client’s condition immediately
- E. Report whether client is using correct gait and balance while ambulating with walker
Correct Answer: B,C,D
Rationale: UAP can place commodes (B), remind about slow position changes (C), report condition changes (D), and observe gait (E). Education (A) requires nursing judgment, unsuitable for delegation.