Nokea
The nurse provides discharge teaching to a client prescribed a cane for left-sided weakness. Which instruction should the nurse provide?
- A. Advance the cane along with your stronger leg.
- B. Remove the rubber tip when going upstairs.
- C. Measure the height of the cane to your elbow.
- D. Secure the cane in your right hand.
Correct Answer: D
Rationale: The cane is held in the right hand (stronger side) for left-sided weakness to support the weaker leg. The stronger leg moves first, rubber tips stay on, and height is measured to the greater trochanter.
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The nurse is performing a home safety assessment for an older adult. What environmental factors should be considered when assessing the client for risk for falls?
- A. Cognitive impairment
- B. Vision loss
- C. Hearing loss
- D. Adequate lighting
Correct Answer: B,D
Rationale: Vision loss and inadequate lighting are environmental factors increasing fall risk. Cognitive and hearing impairments are client-specific, not environmental.
The nurse is reviewing the vital signs of a client admitted with atrial fibrillation. The client's vital signs are: T 37.5°C (99.6°F), P 88 and irregular, RR 20, BP 90/56 mmHg, pulse oximetry reading 96% on room air. The nurse should immediately address which vital sign?
- A. Temperature
- B. Blood pressure
- C. Respiratory rate
- D. Pulse
Correct Answer: B
Rationale: Low BP (90/56 mmHg) indicates potential hemodynamic instability, requiring immediate attention in atrial fibrillation. Temperature, respiratory rate, and pulse are less critical.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with droplet precautions? Select all that apply.
- A. Clostridium difficile
- B. Cryptococcal meningitis
- C. Mycoplasma pneumonia
- D. Haemophilus influenzae, type b pneumonia
- E. Rheumatic fever
- F. Varicella Zoster
- G. Scabies
Correct Answer: C,D
Rationale: Mycoplasma pneumonia and Haemophilus influenzae pneumonia require droplet precautions. Others require contact or standard precautions.
The nurse is performing hand hygiene. Which actions should the nurse take when washing their hands with soap and water? Select all that apply.
- A. Use a paper towel to turn off the faucet.
- B. Keep the hands and forearms lower than the elbows during washing.
- C. Wash hands using hot water.
- D. Rinse the hands and wrists by keeping the hands down and elbows up.
- E. Wash hands for 5 to 10 seconds.
Correct Answer: A,B,D
Rationale: Using a paper towel, keeping hands lower, and rinsing correctly prevent contamination. Hot water is harsh, and washing should last 40-60 seconds.
You are educating a mother about the association between autism and the MMR vaccine. You know that the mother understands your instructions when she says:
- A. My child should not get the vaccine since it is known to cause autism.
- B. My child should get the individual immunizations for measles, mumps, and rubella since the individual vaccines do not cause autism.
- C. My child should get the MMR immunization since there is no evidence that it causes autism.
- D. My child should not get the immunization because it contains mercury.
Correct Answer: C
Rationale: Extensive research shows no link between MMR and autism, and MMR does not contain mercury. Individual vaccines are not standard, and avoiding vaccination is unsafe.