Nokea
The nurse supervises a student assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse
- A. Puts the client's affected (weaker) arm in the shirt's sleeve first.
- B. Places shoes with velcro straps on the client's feet.
- C. Places the wheelchair as close to the bed as possible on the client's affected (weaker) side.
- D. Places the hairbrush in the client's unaffected (stronger) hand.
Correct Answer: C
Rationale: Wheelchair on the affected side hinders transfer; it should be on the unaffected side. Dressing the weaker arm first, velcro shoes, and stronger hand use are correct.
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The right brake on your client's wheelchair is not holding as strongly as the left brake. What is the priority action?
- A. Ask the client if this happened today.
- B. Immediately remove the wheelchair from use.
- C. Try to tighten the brake with a simple tool.
- D. Call the physical therapist for another wheelchair.
Correct Answer: B
Rationale: Removing the wheelchair from use is the priority to prevent falls or injuries due to malfunction.
The nurse is caring for a client immediately following scleral buckling surgery for a retinal detachment of the right eye. Which of the following actions would be appropriate for the nurse to take?
- A. Place the client in a prone position
- B. Approach the client from the left side
- C. Instruct the client to perform deep breathing and coughing exercises
- D. Instruct client to avoid bending down
- E. Orientate the client to the environment
- F. Obtain a prescription for a stool softener
Correct Answer: B,D,E,F
Rationale: Post-scleral buckling surgery, the client’s positioning depends on the surgeon’s orders, but prone positioning is often avoided to prevent pressure on the eye. Approaching from the left side preserves the client’s intact visual field. Deep breathing and coughing may increase intraocular pressure and are typically avoided. Avoiding bending down prevents increased intraocular pressure. Orienting the client to the environment promotes safety due to potential vision changes. A stool softener prevents straining, which could increase intraocular pressure.
The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum
- A. potassium level
- B. calcium level
- C. sodium level
- D. glucose level
Correct Answer: B
Rationale: Total thyroidectomy can disrupt parathyroid function, leading to hypocalcemia due to decreased parathyroid hormone. Monitoring serum calcium levels is critical to detect and manage this complication. Potassium, sodium, and glucose levels are less directly affected by thyroidectomy.
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 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.