Nokea
The nurse is providing home care for a client who is visually impaired. What safety precaution is most appropriate for this client?
- A. Remove scatter rugs.
- B. Have hand rails in the bathroom.
- C. Have side rails up whenever the client is in bed.
- D. Have a bell to call for help.
Correct Answer: A
Rationale: Removing scatter rugs prevents tripping, the most effective safety measure for a visually impaired client at home.
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A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?
- A. Maintaining proper body alignment
- B. Frequent neurovascular assessments of the affected leg
- C. Inspection of pin sites for evidence of drainage or inflammation
- D. Applying an over-bed trapeze to assist the client with movement in bed
Correct Answer: B
Rationale: The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage.
An adult comes to the clinic with complaints of frequency and burning on urination. The nurse expects that what test will be ordered for the client?
- A. Clean catch urine for culture and sensitivity
- B. CBC and electrolytes
- C. Cystoscopy
- D. Strain of all urine for calculi
Correct Answer: A
Rationale: Frequency and burning suggest urinary tract infection; a clean catch urine culture identifies the causative organism and antibiotic sensitivity. CBC, cystoscopy, or straining are less immediate.
The nurse is caring for a client who is terminally ill. When the client dies, the nurse should:
- A. Pronounce the client dead and call the doctor.
- B. Contact the coroner.
- C. Tag the body prior to the funeral home notification.
- D. Request an autopsy.
Correct Answer: C
Rationale: Tagging the body ensures proper identification before transfer to the funeral home. Nurses do not pronounce death, coroner contact depends on policy, and autopsies are not routinely requested.
The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk in this newborn?
- A. Choose an infant carrier with a narrow seat
- B. Place 2 diapers on the infant at all times
- C. Swaddle the infant with hips flexed and abducted
- D. Use an infant swing that keeps both legs straight
Correct Answer: C
Rationale: Swaddling with hips flexed and abducted promotes healthy hip development and reduces dysplasia risk. Narrow carriers and straight-leg swings increase risk, and double diapering is outdated and ineffective.
When counseling a 6 year-old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder?
- A. It has no clear etiology
- B. Enuresis may be associated with sleep phobia
- C. It has a definite genetic link
- D. Enuresis is a sign of willful misbehavior
Correct Answer: A
Rationale: It has no clear etiology. Enuresis has multiple contributing factors, but no single definitive cause has been established.