Nokea
The nurse supervises care of a client in Buck's traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)
- A. The nurse removes the foam boot three times per day to inspect the skin
- B. The staff turn the client to the unaffected side
- C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg
- D. The nurse asks the client to dorsiflex the foot on the affected leg
Correct Answer: C
Rationale: The correct answer is C. Turning the client to the unaffected side helps prevent complications such as pressure ulcers. Dorsiflexion of the foot on the affected leg helps maintain proper alignment and prevent foot drop. The incorrect choices are A and D. Removing the foam boot multiple times per day can disrupt traction, and asking the client to dorsiflex the foot may not be appropriate without ensuring proper alignment and direction from the healthcare provider.
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Which of the following is a nonmedical member of a unit who receives additional training in providing care beyond basic first aid procedures?
- A. Area support squad leader
- B. ATLS specialist
- C. Tactical lifesaver
- D. Combat lifesaver
Correct Answer: D
Rationale: The correct answer is D, Combat lifesaver. A Combat Lifesaver is a nonmedical member of a unit who receives specialized training in advanced first aid procedures, beyond basic first aid care. This training equips them to provide crucial medical assistance in emergency situations where immediate medical personnel may not be available. Choices A, B, and C are incorrect as they do not specifically refer to nonmedical members trained in advanced first aid care beyond basic procedures.
The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?
- A. "I should increase fruits, bran, and fluids in my diet."
- B. "I will use warm compresses and take sitz baths daily."
- C. "I must take a laxative every night and have a stool daily."
- D. "I can use an analgesic ointment or suppository for pain."
Correct Answer: C
Rationale: Choice C indicates the need for further teaching because regular use of laxatives can lead to dependence and is not recommended for hemorrhoids. Increased fiber intake and fluid consumption (Choice A) help prevent constipation, warm compresses and sitz baths (Choice B) provide relief, and using analgesic ointments or suppositories (Choice D) can help manage pain associated with hemorrhoids.
A patient with Crohn's disease is experiencing diarrhea. Which dietary recommendation is appropriate?
- A. High-fiber diet
- B. Low-residue diet
- C. High-fat diet
- D. High-protein diet
Correct Answer: B
Rationale: A low-residue diet is the appropriate dietary recommendation for a patient with Crohn's disease experiencing diarrhea. This diet helps reduce bowel movements and manage diarrhea by limiting the intake of foods that are harder to digest. High-fiber diets (Choice A) may worsen diarrhea due to increased bulk in the stool. High-fat diets (Choice C) can be harder to digest and may exacerbate symptoms. High-protein diets (Choice D) are not specifically recommended for managing diarrhea in Crohn's disease.
In which situation(s) does the nurse act as a client advocate?
- A. Pulling the curtain around the client's bed while changing a dressing
- B. Contacting the health care provider to request a meeting for the client
- C. Ensuring access to medical information by appropriate personnel only
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all the situations listed reflect aspects of client advocacy. Pulling the curtain around the client's bed while changing a dressing ensures privacy and dignity for the client, which is an essential part of advocacy. Contacting the health care provider to request a meeting for the client involves advocating for the client's needs and preferences. Ensuring access to medical information by appropriate personnel only is another way the nurse advocates for the client by safeguarding their confidentiality and promoting proper communication. Choices A, B, and C all demonstrate different aspects of advocacy, making option D the correct choice.
The nurse is teaching the client diagnosed with Type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching?
- A. A submarine sandwich, potato chips, and diet cola
- B. Four (4) slices of a supreme thin-crust pizza and milk
- C. Smoked turkey sandwich, celery sticks, and unsweetened tea
- D. A roast beef sandwich, fried onion rings, and a cola
Correct Answer: C
Rationale: The correct answer is C because a smoked turkey sandwich with celery sticks and unsweetened tea is a healthier option for someone with Type 2 diabetes mellitus. Turkey is a lean protein source, celery sticks are low in calories and carbs, and unsweetened tea is a better choice than sugary beverages. Choices A, B, and D are incorrect. Choice A includes high-carb and high-sugar items like potato chips and diet cola, which are not ideal for diabetes management. Choice B contains a high-carb pizza and milk, which may not be suitable for controlling blood sugar levels. Choice D includes fried onion rings and cola, which are high in unhealthy fats and sugars, making it a poor choice for a diabetic diet.