Nokea
A nurse is caring for a client who is postoperative following total hip arthroplasty.
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.
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A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms.
Which of the following statements should the nurse make?
- A. When using implanted contraceptive methods, condoms should also be used to protect against STDs.
- B. Use of petroleum-based lubricant with a condom increases the condom's effectiveness
- C. Ensure that the condom fits snugly over the tip of the penis
- D. Condoms are equally effective for birth control with or without the use of vaginal spermicides
Correct Answer: A
Rationale: The correct answer is A. This statement is correct because implanted contraceptive methods, like hormonal implants, do not protect against sexually transmitted diseases (STDs), so using condoms is necessary for dual protection. Choice B is incorrect as petroleum-based lubricants can weaken condoms. Choice C is incorrect because a condom should fit comfortably, not snugly, to prevent breakage. Choice D is incorrect because condoms are more effective for birth control when used with spermicide.
Nurses' Notes
Day 1, 0915:
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others.
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate.
Day 1, 0930:
Client questioned about their hallucinations and states that the same person has been following
them around inside and outside the house for days. Client asks the person what they want but
never receives an answer, Client states that this person has never told them to do anything: they
just stare and smile.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, E. Hallucinations, lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all consistent with both psychosis and mania. Hallucinations are sensory perceptions without a real external stimulus, common in both conditions. Lack of sleep is a hallmark symptom of mania and can also exacerbate psychotic symptoms. Excessive spending habits are often seen in manic episodes due to impulsivity, and disorganized thought process and pressured speech are characteristic of both psychosis and mania, reflecting the underlying cognitive and communication disturbances. Other choices are not specific or commonly associated with psychosis or mania.
A nurse is reviewing the medical records of four clients.
The nurse should identify that which of the following client findings requires follow-up care?
- A. A client who received a Mantoux test 48hr ago and has an induration
- B. A client who is schedule for a colonoscopy and is taking sodium phosphate
- C. A client who is taking warfarin and has an INR of 1.8(low INR clotting)
- D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care because it indicates insufficient anticoagulation, putting the client at risk for clot formation. An INR of 1.8 is below the therapeutic range (usually 2-3 for most indications) for warfarin therapy. This can lead to inadequate prevention of blood clots, increasing the risk of thromboembolic events. Follow-up care may involve adjusting the warfarin dosage to achieve the target INR range.
Choice A is incorrect because an induration after a Mantoux test is an expected finding and does not necessarily require follow-up care. Choice B is incorrect as taking sodium phosphate before a colonoscopy is a standard preparation and does not indicate a need for immediate follow-up care. Choice D is incorrect as a potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L
A nurse in an acute care mental health facility is placing a client in seclusion and restraints.
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.
A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hours ago. The nurse notes pink tinged urine and the drainage bag.
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.