Nokea
While ambulating an unsteady client who begins to fall, which of the following actions should the nurse take?
- A. Allow the client to slide down their outstretched leg.
- B. Place their arms around the client to prevent the fall.
- C. Remain upright as the client falls toward them.
- D. Move quickly to a position in front of the client.
Correct Answer: A
Rationale: When a client is falling, allowing them to slide down your leg can help control the descent and prevent injury. This technique ensures a more controlled fall compared to attempting to catch or stop the client abruptly, which could lead to both the client and the nurse getting injured. Placing arms around the client may not provide enough support or control during the fall. Remaining upright or moving quickly in front of the client might not be practical or safe in this scenario.
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A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?
- A. "Get up and change positions slowly."
- B. "Avoid eating aged cheese and smoked meat."
- C. "Report any unusual bruising or bleeding to the doctor immediately."
- D. "Eat the same amount of foods that contain vitamin K every day."
Correct Answer: A
Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.
A client has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?
- A. Ankle-foot orthotic
- B. Continuous passive motion machine
- C. Abduction splint
- D. Sequential compression device
Correct Answer: A
Rationale: An ankle-foot orthotic is the correct choice to prevent a plantar flexion contracture in a paralyzed limb. An ankle-foot orthotic helps maintain proper alignment of the foot and ankle, preventing the foot from being permanently fixed in a pointed-down position. Continuous passive motion machines are typically used to promote joint movement after surgery and would not address the prevention of contractures in this case. Abduction splints are used to keep the legs apart and would not address the specific issue described. Sequential compression devices are used to prevent deep vein thrombosis by promoting circulation in the lower extremities and are not indicated for preventing plantar flexion contractures.
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?
- A. Screening groups of older adults in nursing care facilities for early influenza manifestations
- B. Promoting hand hygiene to prevent the spread of influenza
- C. Administering influenza vaccinations
- D. Educating about the importance of healthy lifestyle choices to prevent influenza
Correct Answer: A
Rationale: The correct answer is A. Secondary prevention aims to detect and address health issues early. Screening older adults in nursing care facilities for early influenza manifestations is an example of secondary prevention by identifying cases at an early stage. Choice B, promoting hand hygiene, is a form of primary prevention that aims to prevent the occurrence of influenza. Choice C, administering influenza vaccinations, is a form of primary prevention as well, focusing on preventing the disease before it occurs. Choice D, educating about healthy lifestyle choices, is more related to health promotion and primary prevention rather than secondary prevention.
A healthcare provider is preparing to insert an IV catheter into a client's arm before starting IV fluid therapy. Which of the following interventions should the provider implement to prevent infection?
- A. Thread the IV catheter so that the hub rests at the insertion site
- B. Shave excess hair from around the insertion site
- C. Cleanse the site with hydrogen peroxide before IV catheter insertion
- D. Palpate the site carefully just before inserting the IV catheter
Correct Answer: A
Rationale: Inserting the IV catheter so that the hub rests at the insertion site reduces the risk of contamination along the length of the catheter. This technique helps prevent introducing microbes into the bloodstream during the catheter insertion process. Shaving excess hair is unnecessary and can increase the risk of skin irritation and infection. Cleansing the site with hydrogen peroxide is outdated as it can cause tissue damage and delay wound healing. Palpating the site just before insertion can introduce bacteria from the skin surface into the insertion site, increasing the risk of infection.
The nurse is providing care for a client who is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely to assess for complications?
- A. Serum potassium
- B. Blood glucose
- C. Serum sodium
- D. Serum calcium
Correct Answer: B
Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the increased risk of hyperglycemia associated with TPN infusion. Elevated blood glucose levels can lead to complications such as hyperglycemia, which can be harmful to the client. While monitoring serum potassium (Choice A), serum sodium (Choice C), and serum calcium (Choice D) are also important aspects of care, when specifically considering TPN administration, blood glucose monitoring takes precedence due to the potential for significant complications related to glucose imbalances.