Nokea
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 5 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
Which of the following instructions should the nurse include when teaching the client how to ambulate with a walker? Select all that apply.
- A. The top of the walker should line up with your wrist crease.
- B. Lean over the walker to maintain good balance.
- C. When going up the stairs, advance the walker up onto the step first.
- D. When getting up from a chair, use the chair's armrests to push yourself up.
- E. Move the walker forward 2 to 4 inches with each step.
Correct Answer: A,D
Rationale: The walker should align with the wrist crease for proper height, and using chair armrests ensures safe standing. Leaning over the walker risks imbalance, and the walker follows the stronger leg on stairs.
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The nursing instructor is supervising a nursing student feeding a client at risk for aspiration. Which action by the nursing student requires follow-up by the nursing instructor? Select all that apply.
- A. Instructs the client to tilt the head backward when drinking.
- B. Reminds the client to assume a chin-down position.
- C. Provides rest periods as needed during the meal.
- D. Positions the client upright for 30-60 minutes after a meal.
- E. Positions the head of the bed at a 45-degree angle during the meal.
Correct Answer: A
Rationale: Tilting the head backward increases aspiration risk. Chin-down position, rest periods, upright positioning, and 45-degree elevation are appropriate.
The nurse cares for a client with a double-lumen peripherally inserted central catheter (PICC). Which of the following actions would be appropriate for the nurse to take?
- A. Assign the client to a private room.
- B. Change the dressing daily using sterile technique.
- C. Flush heparin prior to discontinuation.
- D. Aspirate each lumen for blood return and then flush.
Correct Answer: D
Rationale: Aspirating for blood return and flushing ensures PICC patency. Private rooms, daily dressing changes, and heparin flushing are not standard unless specified.
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.
The nurse has attended a conference on intraoperative nursing interventions for the older adult. which of the following statements by the nurse would indicate the need for additional teaching?
- A. Warming devices should be used to prevent the client from developing hypothermia
- B. The client's head and feet should be covered during surgery
- C. Clients should be slid, not lifted into the proper position
- D. Providing extra padding for clients with decreased peripheral circulation is important
Correct Answer: C
Rationale: Sliding clients instead of lifting can cause shear injuries, particularly in older adults with fragile skin. Warming devices, covering extremities, and extra padding are appropriate to prevent hypothermia and protect pressure points, indicating correct understanding.
A school nurse is discussing poison prevention and management with a group of parents. Which statement by parents would indicate a need for additional teaching?
- A. Containers of poisonous liquids need to be properly labeled.
- B. In the event gasoline is ingested by my child, vomiting should be induced.
- C. I may be able to give my child milk or water to dilute a corrosive poison while I rush them to the hospital.
- D. All poisonous materials should be securely stored away from children.
Correct Answer: B
Rationale: Inducing vomiting for gasoline ingestion is dangerous due to aspiration risk. Labeling, diluting corrosives (if advised), and secure storage are correct.