Step-by-Step Nursing Procedures, and Exam Review||Latest
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A nurse is caring for a client who has a prescription for knee-length
ant embolic stockings. Which of the following actions should the
nurse take?
A. Place the stockings on the client after the client ambulates to the
restroom.
B. Ensure the client's toes are visible after placing the stockings on the
client.
C. After applying the stockings, place two fingers between the client's
leg and stocking to check the fit.
D. Measure the client's calf circumference and leg length from heel to
knee.
D. Measure the client's calf circumference and leg length from heel to
knee.
Rationale: To ensure proper fit, the nurse should measure the widest
part of the client's calf as well as the length of client's leg from heel to
knee. Ant embolic stockings that are too large will not apply the
pressure needed to prevent DVT. Ant embolic stockings that are too
small could impair circulation in the client's legs.
A nurse is assisting with the ambulation of a client who becomes
light-headed and begins to fall. Which of the following actions should
the nurse take?
A. Wrap both arms around the client's arms and shoulders.
B. Move both feet together when the client begins to fall.
C. Protect the client's extremities while lowering them to the floor.
D. Extend one leg and allow the client to slide down the leg to the
floor.
D. Extend one leg and allow the client to slide down the leg to the
floor.
Rationale: This action helps prevent injury to the client. As the client
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,gets close to the floor, the nurse should bend both legs to continue
supporting the client.
A nurse is preparing to transfer a client who has left-sided weakness
from the bed to a chair. Which of the following actions by the nurse
demonstrates correct transfer technique?
A. Positioning the chair slightly behind the nurse so that the seat faces
the client's bed
B. Placing the client's left leg in front of the right leg just prior to the
transfer
C. Aligning the nurse's knees with the client's knees just before the
transfer
D. Grasping the client under the axillae to assist them to their feet
C. Aligning the nurse's knees with the client's knees just before the
transfer.
Rationale: This is a correct strategy that helps the nurse safely
stabilize the client while moving to a standing position.
A nurse is observing assistive personnel (AP) who is using a
mechanical lift w/ a hammock sling to transfer a client from the bed to
a chair. For which of the following actions by the AP should the nurse
intervene?
A. Places a removable cover over the sling
B. Leaves the bed in the lowest position throughout the procedure
C. Locks the hydraulic valve before attaching the sling to the lift
D. Raises the head of the bed to a sitting position just before transfer
B. Leaves the bed in the lowest position throughout the procedure
Rationale: The bed should be raised to a comfortable working position
in order to prevent injury to nursing staff and to properly position the
lift under the client's bed.
A nurse is caring for a client who is at risk for developing atelectasis.
Which of the following actions should the nurse take?
Remind the client to use incentive spirometer
The nurse should remind the client who is at risk for developing
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, atelectasis to use the incentive spirometer. Using the incentive
spirometer prevents atelectasis from occurring because the client
takes slow, deep breaths to promote lung expansion.
A nurse is preparing a poster presentation about the musculoskeletal
system. The nurse should include that which of the following is
responsible for body posture?
Muscles
The skeletal muscles are attached to the skeleton. They maintain body
posture and position.
A nurse is teaching a client who has an unsteady gait about how to use
a walker. Which of the following instructions should the nurse
include?
The top of the walker should be at the level of your wrist
The nurse should reinforce with the client to ensure that the top of the
walker is at the level of their wrist. This indicates the walker is
measured at the appropriate height and prevents strain on the client's
back.
A nurse is caring for a client who has pneumonia. In which of the
following positions should the nurse place the client to promote
postural drainage?
Prone
The nurse should place the client who has pneumonia in the prone
position to promote postural drainage. In this position, the client lies
flat on their abdomen with their head turned to the side.
A nurse is teaching newly hired assistive personnel (AP) about
working with clients who require assistance with ADLs. Which of the
following activities should the nurse include as an ADL?
Toileting
The nurse should include that toileting is an ADL that the AP can
assist the client to perform. Other ADLs include dressing, bathing,
and feeding.
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