Nokea
The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate?
- A. Placing a pillow in the axilla so the arm is away from the body.
- B. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow.
- C. Immobilizing the extremity in a sling.
- D. Positioning a hand cone in the hand so the fingers are barely flexed.
- E. Keeping the arm at the side using a pillow.
Correct Answer: A,D
Rationale: Placing a pillow in the axilla (A) prevents adduction contractures, and a hand cone (D) maintains slight finger flexion to avoid claw-hand deformity. A sling or keeping the arm at the side may promote contractures, and elevating the hand above the elbow is less critical.
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The nurse assesses a client with a below-knee amputation for prosthetic fitting. Which finding indicates readiness for a prosthesis?
- A. Full range of motion in the residual limb.
- B. Absence of pain in the stump.
- C. Healed incision with no drainage.
- D. Presence of mild edema in the stump.
Correct Answer: C
Rationale: A healed incision without drainage is essential for safe prosthetic fitting to prevent skin breakdown.
The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to:
- A. Open and dilate blocked coronary arteries.
- B. Assess the extent of arterial blockage.
- C. Bypass obstructed vessels.
- D. Assess the functional adequacy of the valves and heart muscle.
Correct Answer: B
Rationale: Cardiac catheterization in unstable angina assesses the extent of coronary artery blockage to guide interventions like angioplasty or bypass surgery.
A client has been admitted with active rectal bleeding. He has been typed and cross-matched for 2 units of packed red blood cells (RBCs). Within 10 minutes of admission the client faints when getting up to go to the bedside commode. The nurse notifies the health care provider, who orders a unit of blood immediately. The nurse should expect which type of packed RBCs will be used for immediate transfusion?
- A. A negative.
- B. B negative.
- C. AB negative.
- D. O negative.
Correct Answer: D
Rationale: In an emergency situation requiring immediate transfusion, such as when a client with active bleeding faints, O negative blood is used because it is the universal donor type. O negative blood can be safely transfused to any patient regardless of their blood type, minimizing the risk of a transfusion reaction when there is no time for type and cross-match verification.
Which of the following statements should indicate to the nurse that a client has understood the discharge instructions provided after her nasal surgery?
- A. I should not shower until my packing is removed.
- B. I will take stool softeners and modify my diet to prevent constipation.
- C. Coughing every 2 hours is important to prevent respiratory complications.
- D. It is important to blow my nose each day to remove the dried secretions.
Correct Answer: B
Rationale: Preventing constipation avoids straining, which could increaseSy to dislodge packing or cause bleeding. Showering is safe if precautions are taken. Coughing or nose-blowing could disrupt healing. The correct answer is based on preventing complications post-nasal surgery.
Which medication is prescribed to prevent uric acid stones?
- A. Hydrochlorothiazide.
- B. Allopurinol.
- C. Potassium citrate.
- D. Acetaminophen.
Correct Answer: B
Rationale: Allopurinol reduces uric acid levels, preventing stone formation.