Nokea
Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
- A. Raise the head of the client's bed to a high-fowlers position.
- B. Elevate the clients effected leg on a pillow when in bed.
- C. Position the clients knees slightly higher than the hips when up in a chair
- D. Keep an abduction pillow between the client's legs.
Correct Answer: D
Rationale: The correct answer is D: Keep an abduction pillow between the client's legs. This helps maintain proper alignment and prevents excessive internal rotation of the hip, reducing the risk of dislocation. Elevating the affected leg on a pillow (B) may not provide adequate support. Raising the head of the bed to a high-fowlers position (A) and positioning the knees higher than the hips (C) do not directly address hip alignment.
You may also like to solve these questions
The nurse understands that the patient has likely developed lithium toxicity and will be monitored for-------
- A. blood glucose levels
- B. seizure activity
- C. symptoms of infection
- D. temperature over 39.4° C(103\ F)"
Correct Answer: B
Rationale: The correct answer is B: seizure activity. Lithium toxicity can lead to neurological symptoms including seizures. Monitoring for seizure activity is crucial to prevent serious complications. Blood glucose levels (A) are not typically affected by lithium toxicity. Symptoms of infection (C) are unrelated to lithium toxicity. Monitoring temperature (D) is important but not specific to lithium toxicity.
Which action should the nurse take?
- A. Perform the procedure prior to meals.
- B. Perform chest physiotherapy immediately after feeding.
- C. Place the child in a supine position for the procedure.
- D. Limit fluid intake before the procedure.
Correct Answer: A
Rationale: The correct answer is A: Perform the procedure prior to meals. This is because performing the procedure before meals helps prevent potential complications such as aspiration during feeding. By emptying the stomach before meals, the risk of regurgitation and aspiration is reduced. Choices B, C, and D are incorrect because chest physiotherapy immediately after feeding can increase the risk of aspiration, placing the child in a supine position can also increase the risk of aspiration, and limiting fluid intake before the procedure may lead to dehydration and is not necessary for this specific procedure.
Which finding should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Cessation of nocturnal enuresis
- D. Absence of hypoglycemic episodes
Correct Answer: C
Rationale: The correct answer is C: Cessation of nocturnal enuresis. This indicates the medication is effective because it shows improvement in the condition being treated, which in this case is nocturnal enuresis. Nocturnal enuresis is the involuntary passage of urine during sleep and it can be a result of various factors such as hormonal imbalance or bladder control issues. Therefore, if the medication is effective, it should lead to the cessation of this symptom.
Heart rate (A) and capillary refill (B) are not necessarily indicators of the effectiveness of the medication in treating nocturnal enuresis. Absence of hypoglycemic episodes (D) is more related to diabetes management rather than nocturnal enuresis.
Which of the following food choices is appropriate for this client?
- A. Canned barley soup
- B. Potato pancakes.
- C. Wheat crackers
- D. White flour tortillas
Correct Answer: B
Rationale: The correct answer is B: Potato pancakes. This choice is appropriate as it is likely to be well-tolerated by the client. Potatoes are a good source of carbohydrates and can provide energy. Additionally, potato pancakes are easy to digest and can be a good option for someone with digestive issues. On the other hand, A, C, and D contain grains that may be harder to digest for some individuals, especially if they have digestive concerns. Canned barley soup (A) may also contain added preservatives and sodium, which may not be ideal for the client's condition. Wheat crackers (C) can be high in fiber and may be difficult to digest. White flour tortillas (D) are made from refined grains and may not provide the necessary nutrients for the client.
Which of the following actions should the nurse plan to take?
- A. Document the client's behavior every 15 minutes.
- B. Obtain a prescription for restraints within 4 hours.
- C. Release the restraints every 2 hours to assess circulation.
- D. Discontinue restraints only when the provider removes the order.
Correct Answer: C
Rationale: The correct answer is C: Release the restraints every 2 hours to assess circulation. This action is essential to prevent complications related to impaired circulation and tissue damage. Releasing the restraints allows the nurse to assess the client's circulation, skin integrity, and comfort. It promotes safety and prevents potential harm.
Choice A (Document the client's behavior every 15 minutes) is not the best action as it focuses on behavior rather than safety and circulation. Choice B (Obtain a prescription for restraints within 4 hours) is not necessary as restraints should only be used if all other options have been exhausted. Choice D (Discontinue restraints only when the provider removes the order) is incorrect as the nurse should assess the client's condition independently and not solely rely on provider orders.