Nokea
Which of the following interventions is most appropriate for a client with left-leg weakness who is learning to use a cane?
- A. Maintain two points of support on the floor at all times
- B. Use the cane on the weak side of the body
- C. Advance the cane and the strong leg simultaneously
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct Answer: A
Rationale: The most appropriate intervention for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures stability and helps distribute weight evenly between the legs, reducing the risk of falls. Using the cane on the weak side of the body (Choice B) may not provide adequate support. Advancing the cane and the strong leg simultaneously (Choice C) can lead to imbalance and increases the risk of falls. Advancing the cane too far with each step (Choice D) can also compromise balance and stability.
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A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?
- A. Assess mobility
- B. Monitor vital signs
- C. Provide pain relief
- D. Reinforce discharge teaching
Correct Answer: A
Rationale: Assessing mobility should be the nurse's priority as it ensures the client's safety and helps in developing an appropriate care plan. By evaluating the client's ability to move after the knee arthroplasty, the nurse can identify any immediate issues or complications that need to be addressed promptly. Monitoring vital signs, providing pain relief, and reinforcing discharge teaching are important aspects of care but assessing mobility takes precedence in ensuring the client's immediate well-being and identifying any potential risks.
Which of the following is the best strategy for managing dehydration in a client?
- A. Encourage the client to drink more water
- B. Monitor fluid and electrolyte levels frequently
- C. Administer oral rehydration solutions
- D. Increase the IV fluid rate
Correct Answer: B
Rationale: The best strategy for managing dehydration in a client is to monitor fluid and electrolyte levels frequently. This allows healthcare providers to assess the client's hydration status accurately and make informed decisions regarding treatment. Encouraging the client to drink more water (Choice A) may not be sufficient if the dehydration is severe and requires specific interventions. Administering oral rehydration solutions (Choice C) can be beneficial but should be guided by monitoring the client's condition. Increasing the IV fluid rate (Choice D) may be necessary in certain cases, but it is not always the initial or best approach, as monitoring is crucial to avoid fluid and electrolyte imbalances.
What should a healthcare professional do when they observe signs of phlebitis in a client receiving IV fluids?
- A. Apply a cold compress
- B. Notify the physician immediately
- C. Apply a warm compress
- D. Administer anti-inflammatory medication
Correct Answer: C
Rationale: When signs of phlebitis are observed in a client receiving IV fluids, the appropriate action is to apply a warm compress. This helps to reduce discomfort and swelling at the site of the IV insertion. Applying a cold compress may not be as effective in this case and could potentially worsen the condition. While notifying the physician is important, providing immediate comfort to the client through a warm compress is the initial recommended intervention. Administering anti-inflammatory medication should only be done under the direction of a healthcare provider after assessment and evaluation of the client's condition.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Administer the medication into the client's nondominant arm.
- B. Pull the skin laterally before inserting the needle.
- C. Massage the injection site after administration.
- D. Pinch the skin between the thumb and forefinger.
Correct Answer: D
Rationale: The correct action the nurse should take when administering enoxaparin subcutaneously is to pinch the skin between the thumb and forefinger. Pinching the skin helps to lift the subcutaneous tissue, reducing the risk of injecting into the muscle. Choices A, B, and C are incorrect. Choice A is not relevant as the injection site for enoxaparin is typically in the abdomen or thigh, not the arm. Choice B is incorrect as pulling the skin laterally is not a recommended technique for subcutaneous injections. Choice C is also incorrect as massaging the injection site after administration can increase the risk of bleeding or bruising.
What is the initial step a nurse should take when irrigating a wound?
- A. Wear sterile gloves while removing the old dressing
- B. Cleanse the wound from the center outward
- C. Apply a warm compress to the wound
- D. Use a 20 mL syringe to irrigate the wound
Correct Answer: B
Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.