Nokea
The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client
- A. Exercises both extremities simultaneously.
- B. Knows their heart rate should be monitored while exercising.
- C. Practices forced resistance against stable objects.
- D. Swings their limbs through the full range of motion.
Correct Answer: C
Rationale: Isometric exercises involve static muscle contraction against resistance, like pushing against a stable object. Simultaneous exercise, heart rate monitoring, and full range of motion are not specific to isometrics.
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The first bodily area to be washed during a complete bed bath is the:
- A. Inner canthus of the eye
- B. Cheeks
- C. Forehead
- D. Chin
Correct Answer: A
Rationale: Washing from the inner canthus of the eye outward prevents debris spread and is the starting point for a bed bath. Other areas follow.
The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
- A. obtain a prescription for an antihypertensive
- B. determine if the client's pain is being controlled
- C. assess the client's surgical wound for signs of infection
- D. notify the physician for concerns of hypovolemic shock
Correct Answer: D
Rationale: Without specific clinical data, the priority for a client two days post-gastroduodenostomy is to assess for hypovolemic shock, a potential complication due to bleeding or fluid loss from the surgical site. This is more urgent than pain control, wound infection assessment, or antihypertensive needs, which require specific clinical indicators.
The nurse is preparing to obtain a capillary blood glucose from a client. Place the following actions in the order in which they should be performed, starting from first to last.
- A. Hold the gauze on the client's finger after the specimen has been obtained.
- B. Turn the finger down to promote blood flow with gravity.
- C. Insert strip into monitor.
- D. Prick the side of the finger using the lancet.
- E. Verify and confirm that the code strip corresponds to the meter code.
- F. Disinfect the client's finger with an alcohol swab and allow it to dry.
- G. Read the client's blood glucose level on the monitor.
Correct Answer: E,F,C,D,B,A,G
Rationale: The correct order is: verify strip code (E), disinfect finger (F), insert strip (C), prick finger (D), promote blood flow (B), collect sample and apply gauze (A), read result (G). This ensures accuracy and safety.
The nurse plans to use a mechanical lift to transfer a client from a stretcher to a wheelchair. Which appropriate action should the nurse take?
- A. Keep the stretcher's side rails raised during the transfer
- B. Instruct the client to fold their arms over their chest
- C. Apply gloves and gown for this procedure
- D. Unlock the wheels on the stretcher and wheelchair
Correct Answer: B
Rationale: Instructing the client to fold their arms over their chest prevents interference with the lift and ensures safety. Side rails should be down, gloves/gown are not required, and wheels should be locked.
A nurse is caring for a client with a suspected bowel obstruction who requires a nasogastric (NG) tube insertion. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Begin inserting the tube. Have the client relax and flex their head toward their chest after the tube has passed through the nasopharynx.
- B. Verify tube placement with a radiograph. Check agency policy for specific guidelines.
- C. Encourage the client to swallow by taking small sips of water when possible. Then advance the tube as the client swallows.
- D. Determine the length of the tube to be inserted. Measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum.
- E. Temporarily anchor the tube to the nose with a small piece of tape.
- F. Educate the client on what is going to take place. Instruct client to relax and breathe normally while occluding one naris. Then repeat this action for the other nare. Select the nostril with greater airflow.
- G. Advance the tube each time the client swallows until you reach the desired length.
Correct Answer: F,D,A,C,G,E,B
Rationale: The correct order is: educate the client (F), measure tube length (D), begin insertion (A), encourage swallowing (C), advance to desired length (G), anchor the tube (E), verify placement with radiograph (B). This sequence ensures safe and effective NGT insertion.