Nokea
The nurse is working with an unlicensed assistive personnel (UAP). Which action by the UAP warrants immediate intervention?
- A. The UAP feeds a client two (2) days postoperative cervical laminectomy a regular diet.
- B. The UAP calls for help when turning to the side a client who is post-lumbar laminectomy.
- C. The UAP is helping the client who weighs 300 pounds and is diagnosed with back pain to the chair.
- D. The UAP places the call light within reach of the client who had a disk fusion.
Correct Answer: A
Rationale: A regular diet post-cervical laminectomy risks aspiration if swallowing is impaired; this requires immediate intervention. Calling for help, assisting a heavy client, and placing the call light are appropriate.
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When the nurse examines the client, which body part is usually affected by gout?
- A. Great toe
- B. Index finger
- C. Sacrococcygeal vertebrae
- D. Temporomandibular joint
Correct Answer: A
Rationale: The great toe is commonly affected in gout due to uric acid crystal deposition.
Which assessment finding is the best indication that the client is experiencing secondary complications from the fractured ribs?
- A. Irregular pulse rate
- B. The client's affected leg is shorter than her unaffected leg.
- C. The client's affected leg is shorter than her unaffected leg.
- D. The client's affected leg is executed leg is externally rotated.
- E. The client prefers to sit rather than lie flat.
Correct Answer: E
Rationale: Fractured ribs can cause complications like pneumothorax or hemothorax, leading to difficulty breathing when lying flat. The client's preference to sit upright suggests respiratory distress, a secondary complication. Leg findings are unrelated to rib fractures, and irregular pulse is less specific.
The nurse is preparing to administer subcutaneous Lovenox, a low molecular weight heparin. Which intervention should the nurse implement?
- A. Monitor the client’s serum aPTT.
- B. Encourage oral and intravenous fluids.
- C. Do not eat foods high in vitamin K.
- D. Administer in the anterolateral upper abdomen.
Correct Answer: D
Rationale: Lovenox is administered in the anterolateral abdomen for optimal absorption. aPTT is for unfractionated heparin, fluids are unrelated, and vitamin K affects warfarin.
Which explanation most accurately explains to the client the primary purpose of the splints?
- A. Splints are used to slow joint deterioration.
- B. Splints are used to improve hand strength.
- C. Splints are used to increase range of motion.
- D. None of the above
Correct Answer: A
Rationale: Splints in rheumatoid arthritis are used to rest joints, reducing inflammation and slowing joint deterioration during acute episodes. They do not primarily strengthen hands or increase motion.
The nurse is providing discharge teaching to the 12-year-old with a fractured humerus and the parents. Which information should the nurse include regarding cast care?
- A. Keep the fractured arm at heart level.
- B. Use a wire hanger to scratch inside the cast.
- C. Apply an ice pack to any itching area.
- D. Explain foul smells are expected occurrences.
Correct Answer: A
Rationale: Keeping the arm at heart level reduces edema in a casted humerus. Wire hangers risk skin damage, ice is for swelling not itching, and foul smells indicate infection.