Nokea
Which of the following would be the most appropriate goal for an elderly client
with a nursing diagnosis of risk for injury after hip surgery?
- A. Client will increase mobility by the time of discharge from hospital
- B. Client will demonstrate effective breathing pattern when ambulating throughout
hospital stay - C. Client will increase activity tolerance by discharge from the hospital
- D. Client will remain free from falls throughout their hospital stay
Correct Answer: D
Rationale:
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A client states that he has been experiencing oozing from his wounds. What is
the nurse's priority action?
- A. Insert the wound and assess the drainage
- B. Apply topical ointment to the wound
- C. Call the provider to initiate antibiotics
- D. Culture the wound
Correct Answer: D
Rationale:
What can the nurse NOT teach a client with acquired immunodeficiency syndrome
(AIDS) to reduce the risk of infection?
- A. Share toothpaste with family members
- B. Avoid raw fruits and vegetables
- C. Avoid cleaning your toothbrush with bleach
- D. Wash your hands thoroughly
Correct Answer: A
Rationale:
A client is recovering from a fractured radius that occurred 7weeks ago. Which
state of bone healing occurs at this time as the callus is restored and
transformed into bone?
- A. Stage 3
- B. Stage 5
- C. Stage 1
- D. Stage 4
Correct Answer: D
Rationale:
What is the priority intervention for the nurse to enhance meeting the
psychosocial needs of a client on transmission-based precautions?
- A. Allow the client sleep to build stamina
- B. Provide the client with diversional activities
- C. Maintain a six-foot distance from the client
- D. Provide a timeframe for the isolation
Correct Answer: B
Rationale:
A nurse is caring for a 25-year-old male quadriplegic client. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?
- A. Administer glucosamine supplements
- B. Turn the client every 2 hours
- C. Provide active range of motion (ROM)
- D. Provide passive range of motion (ROM)
Correct Answer: D
Rationale: The correct answer is to provide passive range of motion (ROM). In quadriplegic clients, who have limited or no movement of their limbs, passive ROM exercises are crucial to maintain joint mobility and prevent joint contractures. Administering glucosamine supplements (choice A) is not directly related to promoting joint mobility. Turning the client every 2 hours (choice B) is essential for preventing pressure ulcers but does not directly address joint contracture and mobility. Providing active ROM exercises (choice C) may not be suitable for quadriplegic clients as they are unable to perform these movements on their own.