Nokea
The nursing assistant is caring for an adult who has a fractured femur and is in Buck's extension traction awaiting surgery. The nurse is observing the nursing assistant administer morning care. Which action by the nursing assistant needs correction?
- A. The nursing assistant leaves the weights in place while bathing the client.
- B. The nursing assistant turns the client's head to the side while administering oral hygiene.
- C. The nursing assistant makes the bed from head to foot.
- D. The nursing assistant turns the client on the side for back care.
Correct Answer: D
Rationale: Turning the client on the side disrupts Buck's traction alignment, which requires constant pull. Weights should stay in place, head turning is safe, and bed-making direction is irrelevant.
You may also like to solve these questions
The nurse is caring for a 12-month-old client who is HIV-positive and severely immunosuppressed. Which of the following scheduled immunizations should the nurse anticipate administering to the client? Select all that apply.
- A. Haemophilus influenzae type b
- B. Hepatitis A
- C. Measles, mumps, rubella
- D. Pneumococcal conjugate vaccine
- E. Varicella
Correct Answer: A,D
Rationale: Hib (A) and PCV (D) are inactivated vaccines, safe for immunosuppressed children. MMR (C) and varicella (E) are live vaccines, contraindicated. Hepatitis A (B) is not routine at 12 months.
An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
- A. Review the client's weight pattern over the year
- B. Ask the mother to record her diet for the last 24 hours
- C. Encourage her to talk about her view of herself
- D. Give her several pamphlets on postpartum nutrition
Correct Answer: C
Rationale: Encourage her to talk about her view of herself. To an adolescent, body image is very important, and addressing this concern first facilitates further assessment.
The nurse assists with data collection during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply.
- A. A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week.
- B. I am proud that I was able to lose 10 lb, but I'm still considered obese for my height.
- C. I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently.
- D. I have struggled with daily episodes of acid reflux for years, especially at nighttime.
- E. I snack on a lot of salted foods like popcorn and peanuts.
Correct Answer: A,C,D
Rationale: Smoking cigars (A), heavy alcohol use (C), and chronic acid reflux (D) are established risk factors for esophageal cancer. Obesity (B) is a weaker risk, and salted foods (E) are not directly linked.
The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care?
- A. Discuss the procedure with the client using simple diagrams with correct anatomical terminology
- B. Explore the client's perception of how the surgery will positively affect their future
- C. Focus primarily on the client's feelings and concerns regarding surgical scar appearance
- D. Provide initial education about the procedure to the client immediately before it is performed
Correct Answer: A
Rationale: Using simple diagrams with correct terminology (A) is age-appropriate for a 9-year-old, aiding understanding. Future benefits (B) are abstract, scar concerns (C) are secondary, and last-minute education (D) increases anxiety.
The nurse is caring for all of the following persons. Which one is most in need of restraints?
- A. An elderly man who is sitting in a chair
- B. A confused postoperative client who is picking at his nasal oxygen and nasogastric (NG) tube
- C. A confused woman who is in bed with the side rails up
- D. An adult who has just returned to the surgical floor from a postanesthesia care unit
Correct Answer: B
Rationale: The confused postoperative client risks dislodging critical tubes, necessitating restraints if non-restraint interventions fail. Others pose lower immediate risk.