Nursing Elites

1. Following surgery on the neck, the client asks the LPN why the head of the bed is up so high. The LPN should tell the client that the high-Fowler position is preferred for what reason?

• A. To reduce strain on the incision
• B. To promote drainage of the wound
• C. To provide stimulation for the client
• D. To reduce edema at the operative site

Correct answer: D

Rationale: The high-Fowler position is preferred after neck surgery to reduce edema at the operative site. Elevating the head of the bed promotes venous return and drainage, aiding in decreasing swelling and fluid accumulation, which helps reduce edema at the operative site. Choice A is incorrect as the main purpose is not solely about reducing strain on the incision. Choice B is incorrect because while drainage may occur, it is not the primary reason for maintaining the high-Fowler position. Choice C is incorrect as providing stimulation is not the primary rationale for positioning the client in high-Fowler.

2. A nurse is evaluating a client’s use of a cane. What is the correct use?

• A. Client holds the cane on the stronger side of the body.
• B. Client holds the cane on the weaker side of the body.
• C. Client holds the cane in front of the weaker side of the body.
• D. Client holds the cane in front of the stronger side of the body.

Correct answer: A

Rationale: The correct way to use a cane is for the client to hold it on the stronger side of the body. This positioning allows the cane to provide support to the weaker side, assisting with balance and stability. Placing the cane on the weaker side (Choice B) may not provide adequate support and could lead to an increased risk of falls. Holding the cane in front of the weaker side (Choice C) or in front of the stronger side (Choice D) does not optimize the support and stability needed while walking with a cane.

3. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

• A. Sit on the toilet 30 minutes after eating a meal.
• B. Increase your fluid intake to help with bowel movements.
• C. Exercise regularly to improve bowel function.
• D. Consume more high-fiber foods to prevent constipation.

Correct answer: A

Rationale: The correct statement the nurse should include in the teaching is to 'Sit on the toilet 30 minutes after eating a meal.' This advice can help establish a regular bowel routine and improve bowel movement. Option B, 'Increase your fluid intake to help with bowel movements,' while important, is not specific to the time after eating and does not directly address the need for establishing a routine. Option C, 'Exercise regularly to improve bowel function,' is also important but does not address the timing of bowel movements. Option D, 'Consume more high-fiber foods to prevent constipation,' is beneficial for preventing constipation but does not address the timing aspect related to bowel movements.

4. A parent is reviewing safety measures for an 8-month-old infant with a nurse. Which of the following statements by the parent indicates an understanding of safety for the infant?

• A. “My baby loved to play with the crib gym, but I took it out of the crib.”
• B. “I just bought a firm mattress so my baby will sleep better.”
• C. “My baby really likes sleeping on the fluffy pillow we just got.”
• D. “I put the baby’s car seat on the table after I put him in it.”

Correct answer: A

Rationale: Choice A is correct because removing the crib gym prevents potential safety hazards such as choking or entrapment. Choices B, C, and D are incorrect as they pose risks to the infant's safety. A firm mattress is recommended for infants to reduce the risk of suffocation. Soft mattresses and fluffy pillows increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby's car seat on a table can lead to falls or other accidents.

5. A client reports having insomnia. Which of the following interventions is appropriate for the nurse to recommend?

• A. Exercise 1 hour before bedtime.
• B. Eat a light carbohydrate snack before bedtime.
• C. Drink a cup of hot cocoa before bedtime.
• D. Take a 30-minute nap daily.

Correct answer: B

Rationale: Eating a light carbohydrate snack before bedtime is a suitable intervention for insomnia because it can help stabilize blood sugar levels and promote sleep. Exercising close to bedtime may actually disrupt sleep patterns due to increased alertness and body temperature. Drinking hot cocoa before bedtime, which contains caffeine, may interfere with falling asleep. Taking a nap during the day can make it harder to fall asleep at night and may worsen insomnia. Therefore, the best recommendation among the choices provided is to eat a light carbohydrate snack before bedtime.

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