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Until a translator is available, which nursing action is best when teaching the client who speaks English as a second language about body mechanics?
- A. Speak slowly while looking at the client.
- B. Write the instructions on paper.
- C. See the client and the patient.
- D. Have the client watch a video.
Correct Answer: A
Rationale: Speaking slowly while maintaining eye contact enhances comprehension for a non-native speaker, using nonverbal cues to reinforce verbal instructions until a translator is available.
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While teaching the client, what can the nurse explain about the purpose of stump bandaging?
- A. It lengthens and tones the muscles.
- B. It maintains joint flexibility.
- C. It shapes the stump for prosthesis use.
- D. It absorbs blood and drainage.
Correct Answer: C
Rationale: Stump bandaging shapes the residual limb into a conical form, facilitating prosthetic fitting and reducing swelling. It does not primarily tone muscles, maintain flexibility, or absorb drainage.
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement?
- A. Adjust the patient-controlled analgesia (PCA) machine for a lower dose.
- B. Ensure the weights of the Buck's traction are off the floor and hang freely.
- C. Raise the head of the bed to 45 degrees and the foot to 15 degrees.
- D. Turn the client on the affected leg using pillows to support the other leg.
Correct Answer: B
Rationale: Proper Buck’s traction alignment (weights off floor) reduces pain from misalignment. Adjusting PCA, bed positioning, or turning may worsen pain or are inappropriate.
The client is prescribed Fosamax, a bisphosphonate. Which information should the nurse teach?
- A. Take this medication with a full glass of water.
- B. Take with breakfast to prevent gastrointestinal upset.
- C. Use sunscreen to prevent sensitivity to sunlight.
- D. This medication increases calcium reabsorption.
Correct Answer: A
Rationale: Fosamax is taken with water to prevent esophageal irritation. Food reduces absorption, photosensitivity is not a side effect, and it inhibits bone resorption, not calcium reabsorption.
The client is postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client?
- A. The client will maintain vital signs within normal limits.
- B. The client will have a decrease in muscle spasms in the affected leg.
- C. The client will have no signs or symptoms of infection.
- D. The client will be able to ambulate down to the nurse’s station.
Correct Answer: D
Rationale: Ambulation to the nurse’s station is a long-term goal post-ORIF, indicating restored mobility. Vital signs, spasms, and infection are short-term or secondary.
The client who has sustained a left-sided cerebrovascular accident (stroke) has residual right-sided paralysis. The nurse identifies a concept of impaired functional ability. Which should be included in the care map? Select all that apply.
- A. Refer to the occupational therapist.
- B. Assess the client for neglect of the right side.
- C. Place the client in a room where the door is on the left side.
- D. Teach the client to call for assistance prior to getting out of bed.
- E. Encourage the client to participate in physical therapy daily.
Correct Answer: A,B,D,E
Rationale: OT referral, neglect assessment, fall prevention, and PT promote functional ability post-stroke. Room orientation is less critical.