Nokea
The physician orders passive range-of-motion (ROM) exercises for an elderly client on bed rest. Which statement regarding the performance of ROM exercises is correct?
- A. ROM exercises should be completed independently with verbal cues from the nurse.
- B. Force may be needed during ROM exercises to achieve maximum benefit.
- C. Support should be maintained to the proximal and distal areas of the joint during movement.
- D. ROM exercises should be performed until the client verbalizes discomfort.
Correct Answer: C
Rationale: Supporting the proximal and distal areas of the joint during passive ROM exercises ensures controlled, safe movement, preventing injury. Independent completion, force, or continuing until discomfort risks harm.
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Which nursing intervention is most important after the client returns from the myelogram?
- A. Turning off the room's bright lights
- B. Withholding food and fluids for 12 hours
- C. Administering sedatives every 6 hours
- D. Encouraging a high fluid intake
Correct Answer: D
Rationale: A high fluid intake post-myelogram with water-soluble dye helps excrete the contrast, reducing the risk of complications like seizures or renal issues. Other interventions are less critical.
The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention?
- A. The client’s hemoglobin is 8.1 g/dL.
- B. The client’s white blood cell count is 9,000/mm3.
- C. The client’s creatinine level is 0.8 mg/dL.
- D. The client’s potassium level is 4.2 mEq/L.
Correct Answer: A
Rationale: Hemoglobin of 8.1 g/dL indicates significant blood loss, requiring urgent intervention post-shoulder replacement. Other values are normal.
The physician orders prednisone for a client with rheumatoid arthritis for painful wrists and joints. Which instruction is it essential for the nurse to give the client?
- A. Take the pills with milk or food.'
- B. Be sure to take the medication between meals.'
- C. Stop the pills at once if your face begins to get puffy.'
- D. Your urine may turn pinkish while taking this.'
Correct Answer: A
Rationale: Taking prednisone with food or milk reduces gastrointestinal irritation, a key instruction for safe administration.
The nurse advises the client on the need for maintenance of the bandage. When should the nurse advise the client with a sprained ankle to rewrap the elastic bandage?
- A. When the toes appear pink
- B. When the ankle feels painful
- C. When the toes look swollen
- D. When the joint feels stiff
Correct Answer: C
Rationale: Swollen toes indicate compromised circulation or inadequate compression, necessitating rewrapping to ensure proper fit and pressure. Pink toes suggest normal circulation, pain may not always indicate bandage issues, and joint stiffness is expected with a sprain but not directly related to bandage maintenance.
Which nursing observation provides the best indication that the halo-cervical traction device is applied appropriately?
- A. The client has full range of motion in the neck.
- B. The client's neck pain is within a tolerable level.
- C. The client can speak and hear at preinjury levels.
- D. The client reports the ability to see straight ahead.
Correct Answer: D
Rationale: The ability to see straight ahead indicates proper alignment of the halo device, ensuring the cervical spine is stabilized correctly. Full neck motion contradicts the purpose, and pain or speech/hearing are less specific.