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The nurse is teaching a client how to ambulate using a cane. Which action should the nurse take?
- A. Stand on the client's unaffected (stronger) side during ambulation
- B. Instruct the client to look down at their feet as they ambulate
- C. Instruct the client to move the weaker leg to the cane after placing the cane forward.
- D. Advance the cane 6-10 inches with each step
Correct Answer: A
Rationale: Standing on the stronger side provides support. Looking down risks falls, the stronger leg moves first, and advancement is 12-16 inches.
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The nurse is assessing a client with a history of chronic pain. Which chronic pain assessment focuses on wellness?
- A. Birth history, immunizations, as well as growth and development
- B. Medical history, chronic pain symptoms, and psychosocial factors.
- C. Religion
- D. Sensory deficits, pain management, medication history
Correct Answer: B
Rationale: A wellness-focused chronic pain assessment includes medical history, pain symptoms, and psychosocial factors to optimize quality of life. Birth history, religion, or sensory deficits alone are insufficient.
The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
- A. gentamicin
- B. enoxaparin
- C. hydromorphone
- D. cyclobenzaprine
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is commonly prescribed preoperatively for spinal surgery to prevent venous thromboembolism due to prolonged immobility. Gentamicin is an antibiotic, hydromorphone is for pain, and cyclobenzaprine is a muscle relaxant, none of which are typically prioritized preoperatively for this purpose.
The nurse supervises a student nurse preparing a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student
- A. Asks the client if they have claustrophobia.
- B. Instructs the client to apply earplugs before the exam.
- C. Moves the nitroglycerin patch from the torso to the back.
- D. Tells the client that they will not have any exposure to radiation.
Correct Answer: C
Rationale: Moving a nitroglycerin patch can disrupt medication delivery and is unnecessary for MRI. Asking about claustrophobia, using earplugs, and confirming no radiation exposure are correct.
The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? Select all that apply.
- A. Place a small pillow between the client's knees.
- B. Places the client's arms at their side.
- C. Fanfold a drawsheet along the backside of the client.
- D. Instruct the client to laterally flex the neck during the turn.
- E. Roll the client as one unit in a smooth, continuous motion.
Correct Answer: A,B,C,E
Rationale: Pillow placement, arms at sides, drawsheet use, and rolling as a unit maintain spinal alignment. Neck flexion risks injury during log rolling.
The nurse is caring for a client with a jejunostomy tube receiving intermittent enteral feedings. Which intervention would reduce this client's aspiration risk?
- A. Flush tubing with 10 mL water after feeding is completed
- B. Assess the client's gag reflex prior to feeding
- C. Assess blood glucose every 6 hours
- D. Position the client in semi-Fowler's during and after the feeding
Correct Answer: D
Rationale: Positioning the client in semi-Fowler's (30-45 degrees) during and after feeding reduces aspiration risk by using gravity to prevent gastric contents from refluxing.