Nokea
A nurse is caring for a client who is immobilized. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs.
- D. Apply an orthotic to the client's foot.
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. Contractures are a common complication in immobilized clients, where muscles and tendons shorten and tighten due to lack of movement. Applying an orthotic to the foot helps maintain proper alignment and prevents the foot from being in a fixed position, thus reducing the risk of contractures. Positioning a pillow under the client's knees (A) may help with comfort but does not directly prevent contractures. Placing a towel roll under the client's neck (B) is unrelated to preventing contractures in the lower extremities. Aligning a trochanter wedge between the client's legs (C) is more for hip alignment and may not directly prevent contractures in the foot.
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A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
- A. Increase the amount of refined grains in the client's diet.
- B. Provide the client with a cold drink prior to defecation.
- C. Administer a cathartic suppository 30 min prior to scheduled defecation times
- D. Encourage a maximum fluid intake of 1,500 mL per day.
Correct Answer: C
Rationale: The correct answer is C: Administer a cathartic suppository 30 min prior to scheduled defecation times. This action helps stimulate bowel movement in clients with spinal cord injuries by promoting peristalsis and aiding in bowel evacuation. Increasing refined grains (choice A) may not directly address the bowel-training program. Providing a cold drink (choice B) may not have a significant impact on bowel movements. Restricting fluid intake to 1,500 mL per day (choice D) can lead to dehydration and worsen constipation.
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
- A. How to operate the portable suction machine
- B. How to secure the tracheostomy tube with ties at the back of the neck
- C. How to change the nondisposable tracheostomy tube daily
- D. How to change the tracheostomy dressing using clean technique
Correct Answer: A
Rationale: The correct answer is A: How to operate the portable suction machine. This information is crucial in maintaining a patent airway for the client with a tracheostomy. Suctioning helps to remove secretions and prevent blockages, ensuring proper oxygenation. It is essential for the partner to know how to operate the suction machine safely and effectively.
Choice B is incorrect as securing the tracheostomy tube with ties is important, but it is not the priority in this scenario. Choice C is incorrect as changing the nondisposable tracheostomy tube daily is not a standard practice and can introduce infection risk. Choice D is incorrect as changing the tracheostomy dressing should be done using sterile technique, not clean technique, to prevent infection.
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
- A. Sacrum
- B. Palms of the hands
- C. Shoulders
- D. Area of trauma
Correct Answer: B
Rationale: The nurse should observe the palms of the hands to assess for cyanosis in a client with dark skin because this area is less pigmented and cyanosis is easier to detect. Palms have thinner skin and blood vessels are closer to the surface, making it more likely to show changes in color due to decreased oxygen levels. The sacrum, shoulders, and areas of trauma may not accurately reflect cyanosis in dark-skinned individuals due to the differences in skin pigmentation and thickness. By focusing on the palms, the nurse can accurately assess for cyanosis and provide appropriate care.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client's refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The priority is to assess the client's reasons for refusal to address any barriers preventing compliance, such as fear, pain, or lack of understanding. Understanding the client's perspective can help tailor interventions and address concerns effectively. Requesting a respiratory therapist (choice A) or administering pain medication (choice D) can be secondary once the client's reasons are identified. Simply documenting the refusal (choice C) without addressing the underlying cause does not promote client-centered care.
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Limit alcohol intake to two drinks per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an antibiotic medication.
- D. Place on 2,300 mg sodium diet.
- E. Administer an antihypertensive medication.
- F. Limit foods high in potassium.
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. A - Limiting alcohol intake reduces the risk of adverse health effects. D - A 2,300 mg sodium diet is beneficial for managing blood pressure. E - Antihypertensive medication helps control high blood pressure. B and F are not directly related to planning care for the client. C may not be necessary unless there is an infection present.