Nokea
The nurse is preparing a client with an axillopopliteal bypass graft for discharge. The client should be taught to avoid:
- A. Using a recliner to elevate the legs
- B. Walking long distances
- C. Sitting in a chair for long periods
- D. Sleeping in a flat position
Correct Answer: C
Rationale: Sitting in a chair for long periods post-axillopopliteal bypass risks kinking the graft or pooling blood, impairing circulation and healing a key discharge caution. Elevating legs, walking, or lying flat supports venous return and graft patency. Nurses teach this to prevent thrombosis or occlusion, ensuring clients maintain mobility and positioning to optimize surgical outcomes and limb perfusion.
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The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
- A. That the infant will need daily calcium supplements
- B. To lift the infant by the buttocks when diapering
- C. That the condition is a temporary one
- D. That only the bones are affected by the disease
Correct Answer: B
Rationale: Lifting by the buttocks prevents fractures in osteogenesis imperfecta, a brittle bone disorder calcium doesn't strengthen defective collagen, it's lifelong, and other systems (e.g., hearing) may be affected. Nurses teach gentle handling, ensuring safety in this genetic condition.
Which of the following statement is NOT true about crisis intervention?
- A. Aims to restore pre-crisis state
- B. Short term
- C. Requires long term therapy
- D. Focuses on immediate needs
Correct Answer: C
Rationale: Crisis intervention restores pre-crisis (A), is short-term (B), immediate-focused (D) 'requires long-term therapy' (C) isn't true, as it's brief, per Caplan. C's duration contradicts, making it untrue.
The nurse gave pain medication to Mr. Gary even if he did not ask for it because she assessed that he is in pain. This is an example of?
- A. Autonomy
- B. Beneficence
- C. Justice
- D. Fidelity
Correct Answer: B
Rationale: Giving pain meds unasked, based on assessed need, is beneficence (B) doing good, per ethics. Autonomy (A) respects choice, justice (C) fairness, fidelity (D) promises not proactive care. B fits promoting well-being, making it correct.
The nurse is caring for a client who sustained a traumatic brain injury. Which intervention should the nurse perform to prevent an increase in intracranial pressure (ICP)?
- A. Suction the client every hour
- B. Maintain the head of the bed at 30 degrees
- C. Encourage the client to cough frequently
- D. Administer a bolus of intravenous fluids
Correct Answer: B
Rationale: Maintaining HOB at 30 degrees (B) reduces ICP by aiding venous drainage. Hourly suctioning (A) or coughing (C) raises ICP. Fluid bolus (D) may worsen it. B is correct. Rationale: Elevation optimizes cerebral perfusion pressure while minimizing ICP, per brain injury care standards, unlike actions that increase intrathoracic pressure.
Which of the following statement is NOT true about tort law in nursing?
- A. Covers wrongful acts
- B. Includes negligence
- C. Always criminal
- D. May involve compensation
Correct Answer: C
Rationale: Tort law covers wrongs (A), includes negligence (B), may compensate (D) 'always criminal' (C) isn't true, civil not criminal, per law. C's criminality misstates tort's civil focus, like Mr. Gary's potential claim, making it untrue.