The nurse is caring for a client who just returned from an above-the-knee amputation of the left leg. Which position should the nurse place the client in?
Rationale:
The client should be placed supine, with the affected limb elevated on a pillow. Elevating the limb helps reduce edema and promotes circulation, crucial for healing following an above-the-knee amputation.
A: supine, with the affected limb flat on the bed. Keeping the limb flat can increase swelling and hinder proper circulation, which is detrimental to recovery after surgery.
B: supine, with a wedge pillow between the thighs. A wedge pillow between the thighs does not adequately elevate the affected limb, potentially leading to complications such as increased swelling or discomfort.
D: on the left side with the head of the bed at 30 degrees. Positioning the client on the left side can place unnecessary pressure on the surgical site, impeding healing and increasing discomfort.
A client has orders for placing a nasogastric tube. In which position should the nurse place the client for insertion?
Rationale:
High Fowler's position is ideal for inserting a nasogastric tube. This position facilitates better access to the esophagus, minimizes the risk of aspiration, and ensures the client is more comfortable during the procedure.
A: low Fowler's This position does not provide adequate elevation, which can hinder access to the esophagus and increase the risk of complications during tube insertion.
C: reverse Trendelenburg's This position may cause discomfort and does not align the esophagus properly, making it less effective for safely inserting a nasogastric tube.
D: on the side opposite of the nare used for insertion Placing the client on the opposite side may obstruct the airway and complicate the procedure, making it less efficient and safe.
The nurse is teaching a client diagnosed with gastroesophageal reflux disease (GERD) about dietary measures to manage symptoms. Which food does the nurse advise the client to avoid?
Rationale:
Tomatoes. These are known to aggravate GERD symptoms due to their high acidity, which can lead to increased heartburn and discomfort. Avoiding tomatoes can help in managing and reducing these symptoms effectively.
A: bananas. These are generally considered a low-acid fruit, making them a suitable option for those with GERD, as they are less likely to trigger symptoms.
C: white bread. While it may lack nutritional benefits, white bread is not typically associated with exacerbating GERD symptoms, making it a neutral choice for dietary management.
D: grilled salmon. This protein source is considered beneficial for GERD management, as it is low in fat and can provide essential nutrients without triggering reflux symptoms.
E: steel-cut oatmeal. Oatmeal is often recommended for GERD sufferers due to its ability to absorb stomach acid and provide a soothing effect on the digestive system.
The nurse is teaching infant CPR to a group of newly graduated nurses hired to work in the labor and delivery unit. The nurse understands that proper technique with infants includes which action? Select all that apply.
Rationale:
Chest compression depth should be approximately 1.5 inches, or 4 cm. Activating the emergency response system before CPR is crucial in witnessed arrests, ensuring prompt advanced care for the infant.
A: The femoral artery is checked for a pulse following each cycle of CPR. Checking the femoral pulse is not a standard action during infant CPR; immediate compressions take priority.
C: A single rescuer should use three fingers on the dominant hand to do compressions. Instead, compressions should be delivered using two fingers at the center of the chest for infants.
D: Rest the infant facedown on the forearm with the hand supporting the head and jaw. This position is not appropriate for CPR; infants should be on their back for effective compressions and ventilation.
The nurse is preparing to receive an 18-month-old client from surgery who had repair of a congenital hip deformity. What type of traction does the nurse anticipate setting up for the client?
Rationale:
Bryant’s traction will be set up for the 18-month-old client. This type of traction is specifically designed for children with hip deformities, providing the necessary alignment and support during the recovery phase post-surgery.
B: Russell’s traction This method is typically used for knee or femur fractures, not ideal for hip deformities, thus making it unsuitable for this specific surgical recovery.
C: Buck’s traction Primarily utilized for lower limb injuries, Buck’s traction does not provide the necessary hip stabilization required for post-operative care following congenital hip deformity surgery.
D: Skeletal traction This approach involves invasive methods such as pins or wires, which are generally not suitable for young children recovering from hip surgery, thereby making it less appropriate.
The nurse is caring for a client who is sedated and on the ventilator in ICU. The family expresses concern about controlling the client's pain when he cannot speak. The nurse explains that assessing pain in a nonverbal client involves watching for which of the following signs? Select all that apply.
Rationale:
Nonverbal signs such as biting the ventilator tubing, facial grimacing, stiffness or rigidity of the body, and increased blood pressure and heart rate are crucial indicators of pain in a sedated client.
A: grabbing at the bed rails This behavior may indicate restlessness but is not a specific indicator of pain in nonverbal patients.
E: decreased urinary output While this could suggest discomfort, it is not a direct sign of pain and can be influenced by other factors.
The nurse is assisting the health care provider performing a liver biopsy on a client. How should the nurse position this client? Select all that apply.
Rationale:
Position the client supine with the right upper abdomen exposed and raise the client's right arm and extend it behind the head, over the left shoulder. This positioning facilitates access to the liver, ensuring optimal alignment for the biopsy procedure while minimizing discomfort and risk for the patient.
A: position the client supine with the left upper abdomen exposed. This position does not provide access to the right upper quadrant, where the liver is located.
C: position the client in a low Fowler's with the right upper abdomen exposed. Low Fowler's does not offer adequate access for the biopsy, potentially complicating the procedure and affecting outcomes.
E: raise the client's right arm and extend it across the front of the chest touching the left shoulder. This arm position hinders exposure of the liver and may not align properly with the biopsy site.
The nurse is caring for a client with fluid overload who is on strict I's and O's. The nurse understands that which is the best way to ensure accurate I's and O's?
Rationale:
Accurate I's and O's can best be ensured by clearing any IV pumps and resetting them to zero, allowing for precise measurement of fluid intake from intravenous sources.
A: Clear any IV pumps and reset to zero for accurate IV fluid intake. This method guarantees that all IV fluid administered is accounted for, reflecting true intake levels.
B: Ask the client to keep up with how many cups of fluid he drinks at meals. Relying on the client’s memory may lead to inaccuracies, as self-reporting can be inconsistent.
C: Ask the client to report how much urine is in the urinal each time he uses it. This approach depends on the client’s attentiveness and may not provide comprehensive urine output data.
D: Tell the client not to ask for any extra water or drinks that are not on the meal tray. While this limits intake, it does not directly contribute to accurate measurement and documentation of fluid balance.
The nurse is caring for a client with COPD who complains of poor quality of sleep. Which question should the nurse ask next?
Rationale:
C: How many pillows do you sleep on? This question directly addresses the client's sleep position, which can significantly impact breathing and comfort in individuals with COPD, ultimately influencing sleep quality.
A: Does your partner snore heavily? Although partner snoring can disturb sleep, it does not directly pertain to the client's individual comfort and breathing issues related to COPD.
B: Do you get exercise during the day? While exercise may affect sleep quality, it doesn't specifically address immediate factors related to the client's sleep environment and comfort level.
D: Do you eat large meals right before bed? This question, while relevant to sleep quality, does not focus on the respiratory aspects crucial for a COPD patient’s comfort during sleep.
The nurse is providing dietary instruction to a client with diabetes who has normal kidney function. Which statement by the client requires intervention by the nurse?
Rationale:
Clients with diabetes are encouraged to manage carbohydrate intake carefully, but very low or no carbohydrates can lead to nutritional deficiencies and unstable blood glucose levels, necessitating intervention.
A: I should limit cholesterol intake to 200 mg/day. This aligns with dietary recommendations for individuals with diabetes, aiming to reduce cardiovascular risk through controlled cholesterol consumption.
C: My protein intake should be 15% to 20% of my daily calories. This is appropriate for a diabetic client with normal kidney function, promoting balanced nutrient intake while managing blood sugar levels.
D: Fiber will improve my carbohydrate metabolism and lower cholesterol. This statement correctly highlights the benefits of fiber, which aids in blood glucose control and supports heart health for diabetic individuals.
The nurse is caring for a client who just had a laparoscopic appendectomy. The client tells the nurse that she does not want 'drugs' for pain management, but prefers alternative therapy and/or complementary therapy. Which is the best response by the nurse?
Rationale:
Tell me what works for you, and I will see what we can provide for your comfort. This response acknowledges the client's preferences while inviting collaboration to explore suitable pain management options, demonstrating respect for her choices.
A: I know of some herbs and supplements that you can take to manage the pain. This response assumes knowledge of alternative therapies without ensuring they are safe or appropriate for the client’s specific situation.
C: We use real medicine here in the hospital, so I will bring you hydrocodone for pain when you need it. This dismissive approach undermines the client's preferences and disregards her desire for alternative pain management methods.
D: Yoga always relaxes me. I will get you a foam mat from physical therapy so you can practice when you want. This suggestion may not align with the client’s immediate needs for pain relief and lacks a personalized approach to her care.
A client with gastroesophageal reflux disease (GERD) is talking to the nurse about ways to manage her condition. Which statement reflects an understanding of management of GERD?
Rationale:
Elevating the head of the bed 6 to 12 inches helps reduce nighttime reflux by utilizing gravity to keep stomach acid from flowing back into the esophagus, providing effective symptom relief.
B: Eating a large breakfast and smaller meals for lunch and dinner does not address the underlying issues of GERD, as meal size and timing can still trigger reflux symptoms.
C: Lying on the left side may not directly promote oxygenation; it primarily aids digestion, but frequent swallowing does not effectively clear the esophagus of acid.
D: Taking liquid antacids before and after meals can provide temporary relief, but timing and dosing are critical, and this approach does not address lifestyle modifications necessary for effective GERD management.
The nurse is discharging a client who was prescribed prednisone. The nurse tells the client that one of the side effects may be impaired sleep. The client says, 'I already have a hard time sleeping. What can I do to help with that?' Which recommendations should the nurse make? Select all that apply.
Rationale:
Avoiding alcohol late in the evening, keeping the bedroom dark and quiet, maintaining a consistent sleep schedule, and engaging in quiet activities before bed are all effective strategies to promote better sleep quality. These recommendations help create an optimal sleep environment and routine, minimizing disruptions and enhancing relaxation, which is crucial for individuals struggling with sleep issues.
D: eat a large, heavy meal at dinner to help promote sleep. A heavy meal can lead to discomfort and indigestion, disrupting sleep rather than promoting it effectively.
F: do a vigorous exercise routine after work to help him become tired. Exercising vigorously close to bedtime can stimulate the body, making it harder to wind down and fall asleep.