Nokea
The right brake on your client's wheelchair is not holding as strongly as the left brake. What is the priority action?
- A. Ask the client if this happened today.
- B. Immediately remove the wheelchair from use.
- C. Try to tighten the brake with a simple tool.
- D. Call the physical therapist for another wheelchair.
Correct Answer: B
Rationale: Removing the wheelchair from use is the priority to prevent falls or injuries due to malfunction.
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The nurse is preparing to administer a low-cleansing enema to a client. Which action by the nurse is appropriate during the administration of the enema?
- A. Administer the enema with the client in a supine position.
- B. Insert the enema tube 2 inches into the rectum.
- C. Use cold tap water for the enema solution.
- D. Hang the enema bag approximately 12 inches above the client's rectum.
Correct Answer: D
Rationale: Hanging the bag 12 inches above the rectum ensures proper flow. Supine position is incorrect, insertion is 3-4 inches, and cold water causes cramping.
A nurse is caring for a client with a suspected bowel obstruction who requires a nasogastric (NG) tube insertion. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Begin inserting the tube. Have the client relax and flex their head toward their chest after the tube has passed through the nasopharynx.
- B. Verify tube placement with a radiograph. Check agency policy for specific guidelines.
- C. Encourage the client to swallow by taking small sips of water when possible. Then advance the tube as the client swallows.
- D. Determine the length of the tube to be inserted. Measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum.
- E. Temporarily anchor the tube to the nose with a small piece of tape.
- F. Educate the client on what is going to take place. Instruct client to relax and breathe normally while occluding one naris. Then repeat this action for the other nare. Select the nostril with greater airflow.
- G. Advance the tube each time the client swallows until you reach the desired length.
Correct Answer: F,D,A,C,G,E,B
Rationale: The correct order is: educate the client (F), measure tube length (D), begin insertion (A), encourage swallowing (C), advance to desired length (G), anchor the tube (E), verify placement with radiograph (B). This sequence ensures safe and effective NGT insertion.
The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client
- A. Exercises both extremities simultaneously.
- B. Knows their heart rate should be monitored while exercising.
- C. Practices forced resistance against stable objects.
- D. Swings their limbs through the full range of motion.
Correct Answer: C
Rationale: Isometric exercises involve static muscle contraction against resistance, like pushing against a stable object. Simultaneous exercise, heart rate monitoring, and full range of motion are not specific to isometrics.
The nurse plans to use a mechanical lift to transfer a client from a stretcher to a wheelchair. Which appropriate action should the nurse take?
- A. Keep the stretcher's side rails raised during the transfer
- B. Instruct the client to fold their arms over their chest
- C. Apply gloves and gown for this procedure
- D. Unlock the wheels on the stretcher and wheelchair
Correct Answer: B
Rationale: Instructing the client to fold their arms over their chest prevents interference with the lift and ensures safety. Side rails should be down, gloves/gown are not required, and wheels should be locked.
The nurse supervises a student nurse auscultating lung sounds on a group of clients. Which statement by the student nurse would require follow-up?
- A. Wheezes arise from the small airways and usually do not clear with coughing.
- B. A pleural friction rub causes loud, rough, scratching sounds usually during inspiration.
- C. Thick, tenacious secretions that clear with coughing cause crackles.
- D. Fluid or secretions in large airways typically cause coarse crackles.
Correct Answer: C
Rationale: Crackles are caused by air moving through fluid in small airways and do not typically clear with coughing. Other statements are accurate.