Nokea
To ensure proper immobilization and increase client comfort when using a rigid splint:
- A. place the client on a stretcher before splinting
- B. place the client on a long spine board before splinting
- C. pad the spaces between the body part and the splint
- D. ensure that the splint conforms to the body curves
Correct Answer: C
Rationale: Padding spaces in a rigid splint prevents pressure points, enhancing comfort and ensuring effective immobilization.
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The focus of a nurse case manager is:
- A. nursing care needs at discharge.
- B. the comprehensive care needs of the client for continuity of care.
- C. client education needs upon discharge.
- D. financial resources for needed care.
Correct Answer: B
Rationale: By definition, case management is a process of providing for the comprehensive care needs of a client for continuity of care throughout the health care experience.
To remove a client's gown when she has an intravenous line, the nurse should:
- A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown.
- B. cut the gown with scissors.
- C. thread the bag and tubing through the gown sleeve, keeping the line intact.
- D. temporarily disconnect the tubing from the intravenous container and thread it through the gown.
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.
An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?
- A. inability to turn, cough, and breathe deeply
- B. inability to communicate pain
- C. inability to ambulate freely
- D. inability to use a bedside commode
Correct Answer: B
Rationale: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client.
The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 5 minutes if your NG residual is below 50 mLs.
- C. You can lie down in about 30 minutes.
- D. You can lie down now.
Correct Answer: C
Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure the medications are absorbed.
The NA tells the nurse that the unit's small-adult BP cuff cannot be found and that the client's arm is too small to use a regular adult-sized cuff. Which direction should the nurse give to the NA?
- A. Document the other vital signs and note that the proper-fitting BP cuff is not available.
- B. Go to another nursing unit to obtain their small-adult BP cuff, and take the client's BP.
- C. Use the regular-sized BP cuff and add 10 to the diastolic and systolic BP readings.
- D. If the cuff closes around the arm, take the client's BP using the regular adult cuff.
Correct Answer: B
Rationale: B: A correct-sized cuff ensures accurate BP readings. A: Omitting BP is inappropriate. C: Adjusting readings is inaccurate. D: A too-large cuff gives falsely low readings.