Nokea
Which diagnostic test result should the nurse monitor when assessing for evidence of metastasis?
- A. Lung scan
- B. Urinalysis
- C. Spinal tap
- D. Blood glucose
Correct Answer: A
Rationale: A lung scan can detect metastasis of a skeletal tumor to the lungs, a common site for bone cancer spread. Urinalysis, spinal tap, and blood glucose are less relevant for metastasis.
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The nurse is working with an unlicensed assistive personnel (UAP). Which action by the UAP warrants immediate intervention?
- A. The UAP feeds a client two (2) days postoperative cervical laminectomy a regular diet.
- B. The UAP calls for help when turning to the side a client who is post-lumbar laminectomy.
- C. The UAP is helping the client who weighs 300 pounds and is diagnosed with back pain to the chair.
- D. The UAP places the call light within reach of the client who had a disk fusion.
Correct Answer: A
Rationale: A regular diet post-cervical laminectomy risks aspiration if swallowing is impaired; this requires immediate intervention. Calling for help, assisting a heavy client, and placing the call light are appropriate.
The 32-year-old male client with a traumatic left AKA is being discharged from the rehabilitation department. Which discharge instructions should be included in the teaching? Select all that apply.
- A. Report any pain not relieved with analgesics.
- B. Eat a well-balanced diet and increase protein intake.
- C. Be sure to attend all outpatient rehabilitation appointments.
- D. Encourage the client to attend a support group for amputations.
- E. Stay at home as much as possible for the first couple of months.
Correct Answer: A,B,C,D
Rationale: Reporting unrelieved pain, high-protein diet, rehab appointments, and support groups promote healing and adaptation. Staying home hinders recovery and socialization.
The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first?
- A. Wrap the left hand with towels and apply pressure.
- B. Instruct the friend to hold his hand above his head.
- C. Apply pressure to the radial artery of the left hand.
- D. Go into the friend's house and call 911.
Correct Answer: A
Rationale: Applying pressure with towels controls bleeding, the priority in traumatic amputation. Elevation is secondary, radial pressure is less effective, and calling 911 delays hemorrhage control.
Which return demonstration indicates that the client has understood the correct way to ambulate with the walker?
- A. The client advances the walker and operative leg while putting most of the weight on the walker's handgrips.
- B. The client advances the walker and operative leg while putting most of the weight on the back legs of the walker.
- C. The client advances the walker and operative leg while putting most of the weight on the toes of the operative leg.
- D. The client advances the walker and operative leg while putting most of the weight on the heel of the nonoperative leg.
Correct Answer: D
Rationale: In a three-point partial weight-bearing gait, the client advances the walker and operative leg together, placing most weight on the nonoperative leg's heel to minimize stress on the operative hip, ensuring stability and safety.
Which explanation most accurately explains to the client the primary purpose of the splints?
- A. Splints are used to slow joint deterioration.
- B. Splints are used to improve hand strength.
- C. Splints are used to increase range of motion.
- D. None of the above
Correct Answer: A
Rationale: Splints in rheumatoid arthritis are used to rest joints, reducing inflammation and slowing joint deterioration during acute episodes. They do not primarily strengthen hands or increase motion.