Nokea
Which is most important for the nurse to include in the child's plan of care for a child with spina bifida (myelodysplasia)?
- A. Avoid the child's exposure to latex.
- B. Do intermittent urinary catheterization.
- C. Provide dietary fiber supplements daily.
- D. Complete a referral for physical therapy.
Correct Answer: A
Rationale: Avoiding latex exposure is critical due to the high risk of latex allergy in children with spina bifida.
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The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client?
- A. The occupational therapist.
- B. The physiatrist.
- C. The recreational therapist.
- D. The home health nurse.
Correct Answer: D
Rationale: A home health nurse monitors recovery, manages complications, and supports mobility post-TKR. OT, physiatrists, and recreational therapists are less critical at discharge.
Which instruction should the nurse reinforce to ensure that the exercises are done correctly?
- A. Move your toes toward and away from your head.
- B. Contract and relax your thigh muscles.
- C. The client's effect on the use of the head.
- D. Bend your knee and pull your lower leg upward.
Correct Answer: B
Rationale: Isometric quadriceps-setting exercises involve contracting and relaxing the thigh muscles without joint movement, strengthening the muscle while minimizing stress on the surgical site. The other options describe different movements.
The client with a pelvic fracture developed a fat embolism. The nurse should assess the client for which specific sign?
- A. Dyspnea
- B. Chest pain
- C. Delirium
- D. Petechiae
Correct Answer: D
Rationale: D. The nurse should assess for petechiae. Petechiae (small purplish hemorrhagic spots on the skin) are thought to be due to transient thrombocytopenia. They can occur over the chest, anterior axillary folds, hard palate, buccal membranes, and conjunctival sacs.
Which staff nurse should the charge nurse assign to the client recovering from a repair of the hallux valgus?
- A. A new graduate nurse.
- B. An experienced nurse.
- C. A nurse practitioner.
- D. An unlicensed assistive personnel.
Correct Answer: B
Rationale: An experienced nurse is best suited for postoperative hallux valgus care, requiring skilled assessment. New graduates lack experience, NPs focus on advanced care, and UAPs cannot assess.
The clinic nurse completed teaching the client with a rotator cuff tear who is being treated conservatively. Which client statement indicates that further teaching is needed?
- A. I received a corticosteroid injection in my shoulder to reduce the inflammation and pain.'
- B. Now that the pain is controlled, I can do progressive stretching and strengthening exercises.'
- C. I will continue to take ibuprofen for pain control, but I should take it with food.'
- D. I will need an open acromioplasty to repair the torn cuff after the swelling is reduced.'
Correct Answer: D
Rationale: D. Conservative treatment for a rotator cuff tear typically involves non-surgical methods like corticosteroid injections, physical therapy, and NSAIDs. An open acromioplasty is a surgical procedure and not part of conservative management, indicating a misunderstanding by the client.