Nokea
When the nurse makes rounds at the beginning of the shift, which observation requires the nurse's immediate attention?
- A. The halter rests under the client's chin and occiput.
- B. The client's ears are clear of the traction ropes.
- C. The weight hangs between the headboard and wall.
- D. There is a soft pillow beneath the client's head.
Correct Answer: D
Rationale: A pillow under the head in cervical traction can alter the alignment and reduce traction effectiveness, requiring immediate removal. The other observations indicate proper setup.
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With the assistance of the translator, the nurse correctly instructs the client to use which technique when picking something up?
- A. Squat with the knees bent.
- B. Keep both feet together.
- C. Lift with the arms extended.
- D. Bend from the waist.
Correct Answer: A
Rationale: Squatting with knees bent uses leg muscles to lift, reducing spinal strain and protecting the surgical site post-laminectomy. Bending from the waist or other techniques risks reinjury.
Which statement made by the family member indicates the need for further teaching?
- A. The hand should be elevated higher than the elbow.
- B. The knot should be tied at the back of the neck.
- C. The elbow should be flexed within the sling.
- D. The sling is used to elevate and support the arm.
Correct Answer: B
Rationale: Tying the knot at the back of the neck may cause discomfort or pressure on the cervical spine. The knot should be tied to the side to avoid this. The other statements correctly describe the proper use of a triangular sling for shoulder immobilization.
The nurse identifies the concept of impaired functional ability for a client diagnosed with rheumatoid arthritis. Which intervention should the nurse implement?
- A. Teach the client to apply antiembolism (TED) hose.
- B. Administer the nonsteroidal medication before the morning meal.
- C. Encourage the client to perform low-impact exercises daily.
- D. Refer the client to occupational therapy for gait training.
Correct Answer: C
Rationale: Low-impact exercises maintain joint function in RA, addressing impaired ability. TED hose are for DVT, NSAIDs are for pain, and OT is for specific tasks, not gait.
The client newly diagnosed with osteoporosis is prescribed calcitonin by nasal spray. Which assessment data indicate to the nurse an adverse effect of the medication?
- A. The client complains of nausea and vomiting.
- B. The client is drinking two (2) glasses of milk a day.
- C. The client has a runny nose and nasal itching.
- D. The client has had numerous episodes of nosebleeds.
Correct Answer: C
Rationale: Runny nose and nasal itching are common adverse effects of nasal calcitonin. Nausea is less common, milk intake is unrelated, and nosebleeds are not typical.
Which statement by the nurse about fiberglass casts is most accurate?
- A. Fiberglass casts are less expensive than plaster
- B. Fiberglass casts are lightweight.
- C. Fiberglass casts are flexible.
- D. Fiberglass casts are less restrictive than plaster casts.
Correct Answer: B
Rationale: Fiberglass casts are lightweight compared to plaster, making them more comfortable for clients. They are not necessarily less expensive, flexible, or less restrictive, as both types immobilize effectively.