Nokea
Which nursing instruction is most beneficial to minimize stress on the client's painful joints?
- A. Maintain a normal weight.
- B. Apply a topical analgesic cream.
- C. Take a calcium supplement.
- D. Become more physically active.
Correct Answer: A
Rationale: Maintaining a normal weight reduces mechanical stress on weight-bearing joints like the hip, alleviating pain and slowing osteoarthritis progression. The other options are less impactful for joint stress.
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The client is about to go to surgery but is still wearing a class ring. Which nursing action is most appropriate regarding care of the client's valuables?
- A. Put the ring in the bedside stand.
- B. Tape the ring to the client's finger.
- C. Give the ring to a security guard.
- D. Take the ring to the hospital safe.
Correct Answer: D
Rationale: Valuables like a ring should be secured in the hospital safe to prevent loss or theft during surgery. Leaving it in the bedside stand is insecure, taping it risks circulation issues, and giving it to a security guard is not standard protocol.
The client is scheduled for a magnetic resonance imaging (MRI) scan. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Prepare the client by removing all metal objects.
- B. Inject the contrast into the intravenous site.
- C. Administer a sedative to the client to decrease anxiety.
- D. Explain why the client cannot have any breakfast.
Correct Answer: A
Rationale: Removing metal objects is a safe UAP task, ensuring MRI safety. Contrast injection, sedation, and explanations require nursing judgment.
The client is an elderly man who has had diabetes and peripheral vascular disease for several years. He now has had a right below-the-knee amputation. Which preoperative nursing action will do the most to help the client adjust to having an amputation?
- A. Encouraging deep breathing
- B. Asking him if he understands the full effects of the planned surgery
- C. Discussing the effects of diabetes on the vascular system
- D. Having a recovered amputee visit him
Correct Answer: D
Rationale: A visit from a recovered amputee provides peer support, helping the client adjust by seeing a positive outcome.
The nurse explains that the primary reason for the client's increased risk for altered skin integrity due to a T12 SCI is which factor?
- A. The inability to perceive extremes in temperature leading to burns
- B. The inability to feel skin irritation such as wrinkled linens or clothing
- C. The increased likelihood of bowel and bladder dysfunction and skin irritation
- D. The circulatory changes that cause vasoconstriction and decreased blood supply
Correct Answer: B
Rationale: Loss of sensation below T12 prevents the perception of skin irritants, increasing the risk of pressure ulcers.
The nurse is preparing the preoperative client for a total hip replacement (THR). Which intervention should the nursing implement postoperatively?
- A. Keep an abduction pillow in place between the legs at all times.
- B. Cough and deep breathe at least every four (4) to five (5) hours.
- C. Turn to both sides every two (2) hours to prevent pressure ulcers.
- D. Sit in a high-seated chair for a flexion of less than 90 degrees.
Correct Answer: A
Rationale: An abduction pillow prevents hip dislocation post-THR, a critical complication. Coughing, turning, and chair positioning are important but secondary.