Nokea
Which of the following instructions should the nurse include in the teaching?
- A. Apply cold packs directly on the skin of the affected joints
- B. Administer biological response modifiers to prevent infection
- C. Take a hot shower in the morning to decrease stiffness
- D. Cluster physical activities during the day
Correct Answer: C
Rationale: The correct answer is C: Take a hot shower in the morning to decrease stiffness. This instruction is appropriate for managing symptoms of arthritis by helping to reduce stiffness in the joints. Cold packs directly on the skin (choice A) can worsen symptoms. Administering biological response modifiers (choice B) is not a nursing role. Clustering physical activities during the day (choice D) can help manage symptoms but is not as specific or targeted as a hot shower for reducing stiffness.
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A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has limited mobility due to the oxygen supply and is at high risk for respiratory compromise in a fire. Evacuating this client first ensures their safety and prevents potential harm.
Choice B: A client with a fracture in balance suspension traction requires stabilization but is not in immediate danger during a fire.
Choice C: A bedridden client wearing a hearing aid can be safely evacuated after the oxygen-dependent client.
Choice D: A confused client using a wheelchair may need assistance but is not at immediate risk like the oxygen-dependent client.
The nurse notes that sediment is present in the urine.
- A. Which of the following actions should the nurse take to obtain a sterile urine specimen?
- B. Disconnect the catheter from the collection tubing.
- C. Obtain the specimen from the retention port.
- D. Use the balloon port to obtain the sterile specimen.
- E. Unclamp the collection port below the bag
Correct Answer: B
Rationale: Retention ports allow sterile specimen collection.
A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can go jogging after 2 weeks.â€
- B. I should bend at the waist when putting on my shoes.â€
- C. I can lift objects that are less than 10 pounds.
- D. I can resume activities: such sewing.â€
Correct Answer: D
Rationale: The correct answer is D: "I can resume activities such as sewing." This indicates an understanding of the teaching because it shows the client recognizes the need to avoid strenuous activities that may increase intraocular pressure, thus risking damage to the repaired retina. Sewing is a low-impact activity that does not involve heavy lifting or sudden movements, making it safe for the client postoperatively.
Choice A is incorrect because jogging is a high-impact activity that should be avoided for several weeks post-surgery. Choice B is incorrect because bending at the waist can increase intraocular pressure, which is not recommended post-detached retina repair. Choice C is incorrect as lifting objects, even if less than 10 pounds, can also increase intraocular pressure.
Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes
- B. Use synthetic fabrics for the client’s bedding
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. This is important because nail polish remover contains harsh chemicals that can be harmful if inhaled or absorbed through the skin, especially for clients with compromised health conditions. Applying petroleum jelly (choice A) may not be recommended as it can trap bacteria and cause infection. Using synthetic fabrics for bedding (choice B) may not be ideal as natural fibers are more breathable and comfortable. Cleaning equipment with alcohol-based products (choice C) may not be suitable as it can be irritating to sensitive skin. Therefore, choice D is the best option for the client's safety and well-being.
Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Frequent nosebleeds
- C. Upper extremity hypotension
- D. Increased intracranial pressure
Correct Answer: A
Rationale: Coarctation causes weak or absent femoral pulses.