Nokea
Two unlicensed assistive personnel (UAP) are using the transfer board to move the client from the bed to the wheelchair. Which action should the nursing take?
- A. Take no action because this is the correct procedure for transferring a client.
- B. Instruct the UAPs not to use a transfer board when moving the client.
- C. Tell the UAPs to use the bed scale sling to move the client to the chair.
- D. Request the UAPs to stop and come to the nurse’s station immediately.
Correct Answer: A
Rationale: Using a transfer board is safe and appropriate for bed-to-wheelchair transfers; no action is needed. Other options are incorrect or unsafe.
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Which interventions should the nurse implement for a child with a newly applied fiberglass hip-Spica cast?
- A. Use a hair dryer on a low setting to help dry the cast.
- B. Place on a Bradford frame for elevation off the bed.
- C. Place pillows to support the child's lower extremities.
- D. Turn the child every 2 hours and monitor the CMS.
- E. Petal the perineal area and other edges of the cast.
Correct Answer: C,D,E
Rationale: Pillows provide support, turning prevents pressure sores, and petaling protects skin around cast edges.
In which conditions might the nurse assess for the presence of papilledema?
- A. Eczema
- B. Craniosynostosis
- C. Shaken baby syndrome
- D. Hydrocephalus
- E. Chest trauma
Correct Answer: B,C,D
Rationale: Papilledema, indicating increased intracranial pressure, can be associated with craniosynostosis, shaken baby syndrome, and hydrocephalus.
The nurse writes a concept of 'impaired mobility' for a client diagnosed with a fractured right hip. Which would the nurse include in the plan of care? Select all that apply.
- A. Request a physical therapy referral.
- B. Administer enoxaparin (Lovenox) subcutaneously.
- C. Utilize a gait belt when ambulating the client.
- D. Assess the client’s pain levels on a 1-to-10 scale.
- E. Provide a high-carbohydrate, high-fat, high-sodium diet.
Correct Answer: A,B,C,D
Rationale: PT referral, enoxaparin, gait belt, and pain assessment promote mobility and prevent complications in hip fracture. High-carb/fat/sodium diet is inappropriate.
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 is assessing the client diagnosed with a left femoral neck fracture. Which findings should the nurse expect? Select all that apply.
- A. Left leg is in an abducted position.
- B. Left leg is externally rotated.
- C. Left leg is shorter than the right.
- D. Pain is in the lateral left knee.
- E. Pain is in the groin area.
Correct Answer: B,C,E
Rationale: B. With a left femoral neck fracture, the leg is externally rotated. C. With a left femoral neck fracture, the leg is shortened. E. With a left femoral neck fracture, pain is experienced in the groin area.