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Which of the following activities demonstrate safe client handling practices? Select all that apply.
- A. 1 person assisting a client who is 8 hours post hip replacement surgery with a position change
- B. 1 person using a gait belt while transferring a partial weight-bearing client from the bed to a chair
- C. 2 people repositioning a client who is comatose and has been on the left side for 2 hours
- D. 3 people pulling up in bed a client who weighs 331 lb (150 kg)
Correct Answer: B,C,D
Rationale: Using a gait belt, two people for a comatose client, and three for a heavy client ensure safety and prevent injury. One person for a recent hip replacement risks falls or dislocation due to limited mobility.
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The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?
- A. Administer the prescribed as-needed milk of magnesia
- B. Ask dietary services to add more fruits and vegetables to the client’s tray
- C. Notify the registered nurse
- D. Perform a focused abdominal assessment
Correct Answer: D
Rationale: A focused abdominal assessment determines the cause of constipation (e.g., impaction, obstruction) before interventions like laxatives, dietary changes, or RN notification, ensuring safe and targeted care.
The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
- A. Widening pulse pressure
- B. Pleural friction rub
- C. Distended neck veins
- D. Bradycardia
Correct Answer: C
Rationale: Distended neck veins. Cardiac tamponade causes venous congestion, leading to distended neck veins.
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
- A. Maintain good nutrition
- B. Stay in school
- C. Keep in contact with the child's father
- D. Get adequate sleep
Correct Answer: A
Rationale: Maintain good nutrition. Adequate nutrition, especially protein, vitamins, and iron, is critical for healthy fetal development and reducing low-birth-weight risks.
The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When coming to a conclusion using the Ballard scale, which of these factors may affect the score?
- A. Birth weight
- B. Racial differences
- C. Fetal distress in labor
- D. Birth trauma
Correct Answer: C
Rationale: Fetal distress in labor. The effects of earlier distress may alter the findings of reflex responses as measured on the Ballard tool. Other physical characteristics that estimate gestational age, such as amount of lanugo, sole creases and ear cartilage are unaffected by the other factors.
An 85-year-old woman is hospitalized with a fractured hip. She complains to the LPN/LVN that she feels something is wrong and her chest hurts. The nurse notes the client has tachypnea. What should the nurse do immediately?
- A. Administer oxygen
- B. Take vital signs
- C. Elevate the head of the bed
- D. Give aspirin
Correct Answer: B
Rationale: Chest pain and tachypnea suggest a possible pulmonary embolism post-hip fracture; taking vital signs provides critical data for immediate assessment.