Nokea
The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?
- A. Avoids adjusting the height of the hand grips.
- B. Holds the crutch 6 inches (15 cm) to the side.
- C. Fits the crutch 2 finger widths from axilla.
- D. Walks with the arms fully extended.
Correct Answer: C
Rationale: Proper crutch fit prevents nerve damage.
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The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.
- A. Hand tremors.
- B. Shuffling gait.
- C. Urinary incontinence.
- D. Diminished visual acuity.
- E. Syncope when bending.
Correct Answer: A,B,D
Rationale: Tremors, gait issues, and poor vision impair safe foot care.
The nurse retrieves hydromorphone 4 mg/mL from an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
- A. Incorporate verbal analogies.
- B. Offer positive reinforcement.
- C. Provide physical demonstrations.
- D. Use simulation activities.
Correct Answer: D
Rationale: Simulations promote critical thinking.
The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?
- A. Review the intake and output record.
- B. Give the client 8 ounces of water to drink.
- C. Notify the healthcare provider.
- D. Check the drainage tubing for a kink.
Correct Answer: D
Rationale: Checking for kinks ensures catheter functionality.
During the prodromal stage of an infection, which is the priority nursing intervention?
- A. Develop a plan for gradually increasing activity and mobility.
- B. Begin discharge planning and teaching.
- C. Implement precautions to prevent disease transmission.
- D. Offer the client frequent fluids and ice chips.
Correct Answer: C
Rationale: Precautions prevent infection spread.