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Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis?
- A. Place the client's feet against a firm footboard.
- B. Reposition the client every 2 hours.
- C. Have the client wear ankle-high tennis shoes at intervals throughout the day.
- D. Massage the client's feet and ankles regularly.
Correct Answer: A
Rationale: A firm footboard maintains the foot in a neutral position, preventing plantar flexion contractures. Repositioning, shoes, or massage are less effective for this specific purpose.
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The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the:
- A. Similarities from one side to the other.
- B. Changes from the normal expected findings.
- C. Appearance of age-related wrinkles.
- D. Skin turgor.
Correct Answer: B
Rationale: Noting changes from normal findings is critical, as it helps identify abnormalities like lesions or discoloration that may indicate pathology, beyond expected age-related changes.
Which of the following has been identified as a potential risk factor for the development of colon cancer?
- A. Chronic constipation.
- B. Long-term use of laxatives.
- C. History of smoking.
- D. History of inflammatory bowel disease.
Correct Answer: D
Rationale: A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet. CN: Reduction of risk potential; CL: Analyze
The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours following surgery, the drainage unit is full. The nurse should do which of the following?
- A. Remove the drain from the incision.
- B. Notify the surgeon
- C. Empty drainage.
- D. Record the amount in the unit as output onthe client’s chart.
Correct Answer: C
Rationale: Portable wound suction units can be emptied and drained. The nurse should compress the unit after emptying to create suction before reinserting the plug. It is normal for the suction unit to be full six hours after surgery, and the nurse does not need to notify the surgeon. The drainage unit should be emptied when full or every 8 hours. The drain in the incision should remain in place until the surgeon removes it. While all drainage should be noted as output on the chart, recording the amount without emptying the drainage unit is not accurate nor is it safe practice.
A client has had hoarseness for more than 2 weeks. The nurse should:
- A. Refer to a health care provider for a prescription for an antibiotic.
- B. Instruct the client to gargle with salt water at home.
- C. Assess the client for dysphagia.
- D. Instruct the client to take a throat analgesic.
Correct Answer: C
Rationale: Persistent hoarseness may indicate laryngeal pathology, including cancer; assessing for dysphagia (difficulty swallowing) helps evaluate severity and urgency. Antibiotics are inappropriate without a bacterial diagnosis. Gargling or analgesics may mask symptoms without addressing the cause.
A client with pancreatic cancer is experiencing severe pain and is suspected to have a malignant bowel obstruction. The nurse should anticipate an order for:
- A. A nasogastric tube.
- B. Oral laxatives.
- C. A high-fiber diet.
- D. Immediate surgery.
Correct Answer: A
Rationale: A nasogastric tube is used to decompress the bowel and relieve symptoms in malignant bowel obstruction, providing palliative relief.