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Which goal is most appropriate for a patient who has had a total hip replacement?
- A. The nurse will assist the patient in ambulating in the hall 2 times a day.
- B. The patient will walk 100 feet using a walker by the time of discharge.
- C. The patient will ambulate briskly on the treadmill by the time of discharge.
- D. The patient will ambulate independently by the time of discharge.
Correct Answer: B
Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.
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A client with renal calculi is admitted. What is the priority nursing intervention?
- A. Monitor urinary output every shift.
- B. Administer pain medication as ordered.
- C. Strain all urine for stones.
- D. Increase fluid intake to flush the urinary tract.
Correct Answer: C
Rationale: The correct answer is to strain all urine for stones. This is the priority nursing intervention for a client with renal calculi as it helps in identifying and preventing stones from passing unnoticed. Monitoring urinary output, administering pain medication, and increasing fluid intake are important aspects of care for this client, but the priority is to ensure that any passed stones are collected and analyzed to guide further treatment.
The healthcare provider is assessing an immobile patient for deep vein thrombosis (DVT). What should the healthcare provider do?
- A. Lightly rub the lower leg to check for redness and tenderness.
- B. Apply elastic stockings every 4 hours.
- C. Measure the calf circumference of both legs.
- D. Flex the foot while assessing for patient discomfort.
Correct Answer: C
Rationale: Measuring the calf circumference of both legs is crucial when assessing for DVT in an immobile patient. A significant increase in the circumference of one calf compared to the other suggests the presence of a deep vein thrombosis. Option A is incorrect because rubbing the lower leg may dislodge a clot if present. Option B is incorrect as elastic stockings should not be removed frequently as this can increase the risk of clot formation. Option D is incorrect as dorsiflexing the foot can lead to pain and should not be done to assess for DVT.
What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?
- A. Place the call light within the patient's reach.
- B. Apply a yellow fall risk bracelet to the patient.
- C. Assist the patient when ambulating.
- D. Ensure the patient's room is well-lit.
Correct Answer: B
Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.
The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
- A. I should call 911 if my grandchild loses consciousness.
- B. Never induce vomiting if my grandchild drinks bleach.
- C. If my grandchild eats a plant, I should provide syrup of ipecac.
- D. The number for poison control is 800-222-1222.
Correct Answer: C
Rationale: The correct answer is C. Administering syrup of ipecac is no longer recommended in cases of poisoning. This is because it can lead to complications and is not considered safe. The grandparent should be informed that syrup of ipecac should not be given to a child who has ingested a toxic substance. Choices A, B, and D provide accurate information regarding actions to take in case of poisoning, such as calling 911 if the child loses consciousness, not inducing vomiting if the child drinks bleach, and having the poison control number readily available.
A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?
- A. Patient is lying semiprone.
- B. Patient is lying on side.
- C. Patient is lying on abdomen.
- D. Patient is lying on back.
Correct Answer: B
Rationale: The correct answer is B because the lateral position means lying on the side with body weight on the dependent hip and shoulder. Choice A is incorrect as 'semiprone' means lying on the abdomen with one leg flexed. Choice C is incorrect as 'prone' means lying face down. Choice D is incorrect as 'supine' means lying on the back.