Nokea
The nurse is teaching a client about ambulating with a cane. It would indicate effective teaching if the nurse observes the client
- A. Position the cane on their weaker side.
- B. Advances their weaker leg first, then the cane.
- C. Measures the height of the cane from their wrist crease.
- D. Advances the cane 12-16 inches with each step.
Correct Answer: D
Rationale: Advancing the cane 12-16 inches ensures stability. The cane is held on the stronger side, stronger leg moves first, and height is measured to the greater trochanter.
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Which of the following statements about security in healthcare environments is accurate?
- A. Healthcare facilities must have egress alarms on all doors, except client doors, to maintain security within the facility.
- B. All members of the healthcare facility must have education and training relating to security in the facility.
- C. Members of the healthcare facility who do not have clinical access do not need education and training relating to security in the facility.
- D. Members of the healthcare facility who have only clerical roles do not need education and training relating to security in the facility.
Correct Answer: B
Rationale: All healthcare staff, regardless of role, require security training to ensure safety. Egress alarms are not universally required, and excluding non-clinical or clerical staff is incorrect.
The nurse is preparing to remove a peripheral vascular access device. Which personal protective equipment (PPE) is necessary for this procedure?
- A. Fluid resistant gown
- B. Clean gloves
- C. Surgical mask
- D. Sterile gloves
Correct Answer: B
Rationale: Removing a peripheral vascular access device involves potential blood exposure, requiring clean gloves as standard precautions. A gown, surgical mask, or sterile gloves are not necessary unless additional risks (e.g., infection) are present.
The nurse recognizes which of the following may be used as an approved client identifier? Select all that apply.
- A. first and last name
- B. date of birth
- C. telephone number
- D. admission date
- E. medical record number
- F. age
Correct Answer: A,B,E
Rationale: First and last name, date of birth, and medical record number are approved identifiers per Joint Commission standards. Telephone number, admission date, and age are not.
The following scenario applies to the next 6 items
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 1 of 6
Nurses' Note
Current Medications
1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs 'stiffening up' intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.
Select the three (3) client findings that require immediate follow-up for a 67-year-old female client with progressive multiple sclerosis.
- A. reports of fatigue
- B. heat sensitivity
- C. activity intolerance
- D. medication adherence
- E. ambulation assistance
- F. muscle incoordination
- G. characteristics of pain
Correct Answer: D,E,F
Rationale: Medication adherence (incomplete antibiotic course) risks recurrent cystitis, ambulation assistance (using furniture) indicates fall risk, and muscle incoordination increases injury risk, requiring immediate intervention.
Item 1 of 1
• Nurses' Notes
0920: Client presents for a follow-up visit. Client reports increased difficulty with activities of daily living because of dyspnea. Reports pain and swelling in both lower extremities that increases with movement. "Washing my hair now takes me an hour instead of fifteen minutes." Transverse surgical incision was pink, approximated, and crusted—9 inches in length. Two Jackson-Pratt drains contained a total of 15 mL of serumlike drainage. Incisional pain reported at a '4' on the Numerical Rating Scale. Endorses increased incisional pain while coughing. The client reports full adherence to postoperative enoxaparin self-injections. She reports ejecting the air bubble prior to injection. Reports relief with prescribed oxycodone-acetaminophen but experiences generalized itching and drowsiness after.
• Medical History
• gastric bypass surgery performed two years ago
• dyslipidemia
• diabetes mellitus (type two)
• Vital Signs
• T 99.0°F (37.2°C); HR 90 beats/min; RR 18 breaths/min; BP 119/67 mm Hg; Pulse oximetry 96% on room air.
The nurse in the medical office is caring for a 41-year-old client who is 2-week postoperative abdominoplasty. Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. wound assessment findings
- B. tolerance with activities of daily living
- C. pain in lower extremities
- D. enoxaparin self-injections
- E. pulse, respirations, and blood pressure
Correct Answer: B,C,D
Rationale: Tolerance with activities of daily living. The client reports increased difficulty with activities of daily living (ADLs) due to dyspnea, which could indicate a significant complication, such as pulmonary embolism (PE). Dyspnea, especially in the postoperative period, should always be investigated promptly, as it could be a sign of a PE, which is a life-threatening emergency. Immediate follow-up is necessary to rule out PE or other respiratory or circulatory issues. Pain in lower extremities. Pain and swelling in the lower extremities that increase with movement could suggest deep vein thrombosis (DVT). This complication is especially concerning in a postoperative patient on anticoagulation therapy (enoxaparin). DVT can lead to pulmonary embolism if the clot dislodges, which could cause dyspnea. This requires immediate follow-up to assess for DVT and initiate treatment if necessary. The client reports full adherence to postoperative enoxaparin self-injections and mentions ejecting the air bubble before injection. This is an incorrect technique; ejecting the air bubble can result in an underdose of the medication, potentially leading to ineffective anticoagulation. This can increase the risk of complications like DVT or VTE. Correct technique is crucial to ensure proper dosing. Immediate follow-up is required to educate the client about appropriate injection techniques (not ejecting the air bubble) to prevent these risks.Wound assessment findings. The transverse surgical incision is described as pink, approximated, and crusted, which are normal findings in the early postoperative period. These findings suggest no signs of infection or delayed wound healing. Therefore, no immediate follow-up is required for this finding.Incision pain level and characteristics. The client reports incisional pain at a level of 4 on the Numerical Rating Scale and increased pain when coughing. This level of pain is within a manageable range for a postoperative patient. The description of the pain as incisional and aggravated by coughing is consistent with expected postoperative discomfort. The pain level is manageable, and this is not a priority concern for immediate follow-up unless it becomes severe or is associated with other complications (e.g., infection or dehiscence).