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1. A client who has a new prosthesis for an above-the-knee amputation of the right leg needs teaching on its use. Which of the following instructions should the nurse include?
- A. Wear the prosthesis for 2 hours at a time
- B. Remove the prosthesis every other day
- C. Apply the prosthesis immediately upon waking each day
- D. Elevate the stump for 24 hours after applying the prosthesis
Correct answer: C
Rationale: The correct instruction is to apply the prosthesis immediately upon waking each day. This helps the client adjust to and maintain mobility. Choice A is incorrect because wearing the prosthesis for only 2 hours at a time may not be sufficient for proper adjustment. Choice B is incorrect as removing the prosthesis every other day is not a standard practice and may hinder the client's mobility. Choice D is incorrect because elevating the stump for 24 hours after applying the prosthesis is unnecessary and not a recommended practice.
2. What are the key interventions for managing a patient with asthma?
- A. Administer bronchodilators and monitor oxygen levels
- B. Encourage deep breathing exercises
- C. Provide corticosteroids and monitor for respiratory distress
- D. Provide antihistamines and monitor blood pressure
Correct answer: A
Rationale: The correct answer is A: Administer bronchodilators and monitor oxygen levels. Asthma management involves using bronchodilators to help open the airways and improve breathing. Monitoring oxygen levels is essential to ensure the patient is getting enough oxygen. Choice B, encouraging deep breathing exercises, can be helpful for some respiratory conditions but is not a key intervention for managing an acute asthma attack. Choice C, providing corticosteroids and monitoring for respiratory distress, is important for long-term asthma management and severe exacerbations but is not the immediate key intervention during an acute attack. Choice D, providing antihistamines and monitoring blood pressure, is not typically indicated for asthma management as asthma is primarily an airway disease, not a histamine-mediated condition.
3. A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will position the car seat in the front seat
- B. I will secure the car seat in the car by using the seatbelt
- C. I will use a rear-facing car seat
- D. I will install the car seat facing forward
Correct answer: C
Rationale: The correct answer is C. Using a rear-facing car seat is the safest position for a newborn. Newborns should always be placed in a rear-facing car seat in the back seat of the vehicle to provide optimal safety in case of a crash. Choice A is incorrect because placing the car seat in the front seat is not safe due to the presence of airbags. Choice B is incorrect as securing the car seat using the seatbelt is not specific to the correct positioning of the car seat. Choice D is incorrect because installing the car seat facing forward is not recommended for newborns as it does not provide the same level of protection as a rear-facing position.
4. A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?
- A. Remove the weights
- B. Ensure the weights hang freely
- C. Increase the traction force
- D. Loosen the ropes
Correct answer: B
Rationale: The correct action the nurse should take when caring for a client in Buck's traction is to ensure the weights hang freely. This is essential to maintain proper alignment and ensure the effectiveness of Buck's traction. Removing the weights (Choice A) would be incorrect and could compromise the treatment. Increasing the traction force (Choice C) can lead to excessive pressure and potential harm to the client. Loosening the ropes (Choice D) would also be inappropriate as it can disrupt the traction's effectiveness and alignment.
5. Which is the correct method for teaching a client to use a cane when they have left-leg weakness?
- A. Use the cane on the weaker side of the body
- B. Advance the cane and the strong leg together
- C. Maintain two points of support on the floor at all times
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct answer: C
Rationale: The correct method for teaching a client to use a cane when they have left-leg weakness is to maintain two points of support on the floor at all times. This approach ensures stability and helps the client maintain balance while using the cane. Choice A is incorrect because the cane should be used on the stronger side of the body to provide additional support. Choice B is incorrect as advancing the cane and the strong leg together may compromise stability. Choice D is incorrect as advancing the cane too far with each step can lead to imbalance and falls.
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