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The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?
- A. Maintain a narrow base of support.
- B. Dangle the patient at the bedside.
- C. Encourage isometric exercises.
- D. Suggest a high-calcium diet.
Correct Answer: B
Rationale: The correct action the nurse should take first when a patient needs to be mobilized after being in bed for several days is to dangle the patient at the bedside. Dangling at the bedside is the initial step to assess the patient's tolerance to sitting up and moving. It helps prevent orthostatic hypotension and allows the nurse to evaluate the patient's response to upright positioning before attempting further ambulation. Maintaining a narrow base of support (Choice A) is related to assisting with ambulation but is not the first step. Encouraging isometric exercises (Choice C) and suggesting a high-calcium diet (Choice D) are not immediate actions needed to initiate mobilization in this scenario.
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A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?
- A. Capillary refill of 4 seconds
- B. 7.5 cm (3 in) diameter bruise on the ankle
- C. Warts on the affected ankle
- D. 2+ pitting edema
Correct Answer: A
Rationale: The correct answer is A. Capillary refill of 4 seconds indicates poor circulation, which is a contraindication to cold application as it could worsen the condition by further reducing blood flow. Choice B, a 7.5 cm (3 in) diameter bruise on the ankle, does not directly contraindicate cold application but may need evaluation for possible underlying injuries. Choice C, warts on the affected ankle, do not necessarily contraindicate cold application. Choice D, 2+ pitting edema, is not a direct contraindication to cold application but may need to be addressed separately.
A healthcare professional is providing care to a client who has a tracheostomy. Which of the following actions should the professional take to prevent complications?
- A. Clean around the stoma with povidone-iodine.
- B. Maintain sterile technique when performing tracheostomy care.
- C. Use clean technique when suctioning the tracheostomy.
- D. Change tracheostomy ties weekly.
Correct Answer: B
Rationale: Maintaining sterile technique when performing tracheostomy care is essential in preventing infections and complications. Option A is incorrect because povidone-iodine may be too harsh for cleaning around the stoma and can lead to skin irritation. Option C is incorrect because suctioning a tracheostomy should be done using sterile technique to minimize the risk of introducing pathogens. Option D is incorrect as tracheostomy ties need to be changed more frequently, usually every 1-2 days, to prevent skin breakdown and infection.
A client has a new prescription for a metered-dose inhaler. Which of the following instructions should the nurse include?
- A. Inhale quickly and deeply while pressing down on the inhaler.
- B. Hold your breath for 10 seconds after inhaling the medication.
- C. Exhale immediately after inhaling the medication.
- D. Shake the inhaler before each use.
Correct Answer: B
Rationale: The correct instruction for using a metered-dose inhaler is to hold your breath for 10 seconds after inhaling the medication. This allows the medication to be absorbed more effectively in the lungs. Inhaling quickly and deeply while pressing down on the inhaler (Choice A) may cause the medication to deposit in the mouth and throat rather than reaching the lungs. Exhaling immediately after inhaling the medication (Choice C) may also lead to medication wastage. Shaking the inhaler before each use (Choice D) is not necessary for all types of inhalers and can sometimes cause improper drug delivery.
A client is immobile due to a cast, and a nurse is assisting in the use of a fracture bedpan. Which of the following actions should the nurse take?
- A. Place the shallow end of the fracture pan under the client's buttocks.
- B. Encourage the client to remain immobile on the fracture pan for 20 minutes.
- C. Keep the bed flat while the client is on the fracture pan.
- D. Hyperextend the client's back while the fracture pan is in place.
Correct Answer: A
Rationale: The correct action when using a fracture bedpan for an immobile client is to place the shallow end of the pan under the client's buttocks. This positioning helps in proper collection of feces without causing discomfort or injury. Encouraging the client to try to defecate for 20 minutes (Choice B) is inappropriate and unrealistic, as defecation should not be forced or timed. Keeping the bed flat (Choice C) is incorrect as elevating the head of the bed can help promote proper positioning for bedpan use. Hyperextending the client's back (Choice D) is contraindicated and can lead to discomfort and potential injury to the client.
A healthcare professional is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the healthcare professional take?
- A. Examine personal values about the issue.
- B. Respect the parents' decision and provide alternative treatment options.
- C. Seek a court order to proceed with the transfusion.
- D. Discuss the issue with the child.
Correct Answer: A
Rationale: Examining personal values about the issue is crucial for the healthcare professional to provide unbiased care while still respecting the parents' beliefs. Choice B is incorrect because respecting the parents' decision is essential, but providing alternative treatment options may not be warranted in this situation where the parents' decision is based on religious beliefs. Seeking a court order (Choice C) should only be considered as a last resort when the child's life is in immediate danger and all other options have been exhausted. Discussing the issue with the child (Choice D) may not be appropriate as the child may not fully comprehend the situation or the implications of going against the parents' beliefs.