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The nurse is planning care for a client with a fractured humerus in a sling. Which intervention should be included?
- A. Encourage shoulder shrugging exercises.
- B. Apply heat to the fracture site.
- C. Keep the arm in a dependent position.
- D. Restrict all arm movement.
Correct Answer: A
Rationale: Shoulder shrugging exercises maintain mobility and prevent stiffness without stressing the fracture.
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What is the nurse's best action for a client with a migraine headache?
- A. Administer oxygen.
- B. Provide a quiet, dark environment.
- C. Encourage fluid restriction.
- D. Apply a warm compress.
Correct Answer: B
Rationale: A quiet, dark environment reduces stimuli that exacerbate migraine symptoms.
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) accurately reflects the client's rapid tiring due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported by the symptoms described.
Which intervention is appropriate for a client on hemodialysis?
- A. Check fistula for a thrill.
- B. Restrict all fluids.
- C. Administer heparin post-dialysis.
- D. Encourage high-protein diet.
Correct Answer: A
Rationale: Checking for a thrill ensures fistula patency for dialysis.
Several clients who work in the same building are brought to the emergency department. They all common to the patient's condition. Including fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. Upon initial assessment, the nurse finds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was inflated. Which isolation precautions should the nurse initiate?
- A. Contact isolation with double-gloving and shoe covers.
- B. Respiratory isolation with positive pressure rooms.
- C. Enteric precautions.
- D. Reverse isolation.
Correct Answer: A
Rationale: Symptoms suggest a hemorrhagic fever (e.g., Ebola), requiring contact isolation with enhanced precautions like double-gloving and shoe covers to prevent transmission.
The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions?
- A. Determining the client's knowledge level about cholesterol.
- B. Asking the client to name foods that are high in fat, cholesterol, and salt.
- C. Explaining the importance of complying with the diet.
- D. Assessing the client's and family's typical food preferences.
Correct Answer: D
Rationale: Assessing food preferences ensures the dietary plan is tailored and practical.