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 is initiating the client's plan of care. Which of the following Interventions should the nurse plan to implement?
- A. Provide a low-stimulation environment.
- B. Maintain bed rest.
- C. Give antihypertensive medication.
- D. Administer betamethasone
- E. Monitor intake and output hourly.
- F. Obtain a 24 hr urine specimen.
- G. Perform a vaginal examination every 12 hr.
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes providing a low-stimulation environment (A) for client comfort, maintaining bed rest (B) to promote healing, giving antihypertensive medication (C) for blood pressure management, administering betamethasone (D) for specific medical needs, monitoring intake and output hourly (E) for fluid balance assessment, and obtaining a 24 hr urine specimen (F) for diagnostic purposes. These interventions are essential in addressing the client's physical and physiological needs during care planning. Performing a vaginal examination every 12 hr (G) is not typically indicated and may not be necessary unless specifically ordered for a particular condition.
Which of the following actions should the nurse take?
- A. Maintain the irrigation solution rate.
- B. Increase the irrigation solution rate.
- C. Clamp the catheter for 30 minutes and reassess.
- D. Notify the provider immediately.
Correct Answer: A
Rationale: The correct answer is A: Maintain the irrigation solution rate. This is the appropriate action because maintaining the irrigation solution rate ensures continuous flushing of the catheter to prevent blockages and maintain patency. Increasing the rate could lead to complications like fluid overload. Clamping the catheter and reassessing can cause catheter obstruction. Notifying the provider immediately may not be necessary unless there are specific complications or concerns.
Nurse is planning care for a child during admission to the facility. Which action should the nurse take first?
- A. Obtain a prescription for pain medication.
- B. Collect blood cultures
- C. Transport the child to obtain a CT scan.
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: Positive Brudzinski's and Kernig's signs indicate meningitis, making seizure precautions the priority to prevent complications.
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B,C,D
Rationale:
The correct answer is B, C, D.
B: Painful, tender breast - This finding is consistent with mastitis, which is an infection of the breast tissue.
C: Temperature - This finding is common in both mastitis and endometritis, indicating an infection.
D: Chills - This finding is more indicative of a systemic infection, often seen in endometritis.
Explanation for incorrect choices:
A: Foul-smelling lochia - This finding is more specific to endometritis, not mastitis.
E, F, G: Since these parameters are not provided, they cannot be selected or checked.
Which finding should the nurse identify as expected?
- A. Weak femoral pulses
- B. Bounding pulses in the lower extremities
- C. Cyanosis of the hands and feet
- D. Frequent episodes of bradycardia
Correct Answer: A
Rationale: The correct answer is A: Weak femoral pulses. In pediatric patients, weak femoral pulses are expected due to the normal physiological differences in vascular resistance between upper and lower extremities. This is known as the "femoral pulse lag." Bounding pulses in the lower extremities (choice B) would be abnormal and could indicate a vascular disorder. Cyanosis of the hands and feet (choice C) suggests poor perfusion and oxygenation, which is concerning. Frequent episodes of bradycardia (choice D) could indicate cardiac issues and are not expected in a healthy pediatric patient.