Nokea
Which staff nurse should the charge nurse assign to the client recovering from a repair of the hallux valgus?
- A. A new graduate nurse.
- B. An experienced nurse.
- C. A nurse practitioner.
- D. An unlicensed assistive personnel.
Correct Answer: B
Rationale: An experienced nurse is best suited for postoperative hallux valgus care, requiring skilled assessment. New graduates lack experience, NPs focus on advanced care, and UAPs cannot assess.
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The nurse writes the problem of 'pain' for a client diagnosed with lumbar strain. Which nursing interventions should be included in the plan of care? Select all that apply.
- A. Assess pain on a 1-to-10 scale.
- B. Administer pain medication prn.
- C. Provide a regular bedpan for elimination.
- D. Assess surgical dressing every four (4) hours.
- E. Perform a position change by the log roll method every two (2) hours.
Correct Answer: A,B,E
Rationale: Pain assessment, PRN medication, and log rolling address pain and prevent exacerbation in lumbar strain. Bedpans are unnecessary, and surgical dressings are irrelevant without surgery.
Which area of health teaching is essential to include in the discharge instructions for a client who has undergone a total hip replacement?
- A. Modifying ways of donning clothing
- B. Using special equipment for bathing
- C. Taking vigorous daily walks
- D. Receiving a daily stool softener
Correct Answer: A
Rationale: Modifying clothing application prevents excessive hip flexion.
Which nursing instruction about heating pads is essential to include in the client's teaching plan?
- A. Use the lowest setting on the heating pad.
- B. Place the heating pad directly on the skin.
- C. Cover the heating pad with plastic during use.
- D. Apply the heating pad for 2 hours at a time.
Correct Answer: A
Rationale: Using the lowest setting on the heating pad minimizes the risk of burns, especially in older clients with potentially reduced skin sensitivity. Direct skin contact, plastic covers, or prolonged use increase burn risk.
To which member of the health-care team should the nurse refer the client diagnosed with OA who is complaining of not being able to get in and out of the bathtub?
- A. Physiatrist.
- B. Social worker.
- C. Physical therapist.
- D. Counselor.
Correct Answer: C
Rationale: A physical therapist can teach adaptive techniques and exercises to improve bathtub mobility for OA. Physiatrists focus on rehabilitation plans, social workers address resources, and counselors focus on mental health.
The client with a lower leg amputation has edema, so the NA elevates the client's residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client's leg has been elevated?
- A. Thank the nursing assistant (NA) for being so observant and intervening appropriately to treat the client's edema of the residual limb.
- B. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture.
- C. Inform the NA that this was the correct action at this time in the client's recovery, but once the client's incision heals, the leg should not be elevated.
- D. Report the incident to the surgeon and tell the NA to complete a variance report because the client's leg should not have been elevated.
Correct Answer: B
Rationale: B. The nurse should perform this action. Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture.