A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Restrict visitors to family members until the client is able to wear a prosthesis.

Encourage the client to talk with another client who completed rehabilitation for amputation.

Instruct the client to ignore phantom pain sensations.

Suggest that family members bring clothing for the client from home.

Ask the client to describe her feelings about the loss of the affected limb.

Answer and Explanation

Correct Answer : B,D,E

A. Restrict visitors to family members until the client is able to wear a prosthesis: Restricting visitors may increase isolation and hinder emotional support.
B. Encourage the client to talk with another client who completed rehabilitation for amputation: Peer support can provide emotional reassurance and motivate the client in their recovery process.
C. Instruct the client to ignore phantom pain sensations: Phantom pain is real and should not be dismissed; it requires management through medication or other interventions.
D. Suggest that family members bring clothing for the client from home: Familiar clothing can improve self-esteem and promote adjustment to body image changes.
E. Ask the client to describe her feelings about the loss of the affected limb: Exploring the client’s feelings helps address emotional and psychological aspects of coping with amputation.

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Correct Answer is A

Explanation

A. Initiate fall precautions: Fall precautions are essential for clients with aspiration pneumonia and hypoxia as they may be disoriented or have impaired oxygenation, increasing the risk of falls.
B. Applying petroleum jelly to the client's nares is not appropriate in this case, as it does not address the client's aspiration pneumonia or hypoxia.
C. Implementing contact precautions is not necessary for aspiration pneumonia unless there is a specific infection that requires isolation precautions (e.g., bacterial infections).
D. Maintaining the client in a supine position can worsen hypoxia and aspiration, as it can facilitate fluid or food moving into the lungs. The client should be maintained in an upright position to promote better oxygenation and prevent aspiration.

A. "It is common for the skin on my breasts to dimple. B. "I will perform breast exams every other month." C. "It is common for one breast to be larger than the other D. "I will perform breast exams the day my period begins."

Correct Answer is C

Explanation

A. "It is common for the skin on my breasts to dimple": Dimpling can be a sign of breast cancer due to underlying tissue changes and should be evaluated.
B. "I will perform breast exams every other month": BSE should be done monthly to detect any changes early.
C. "It is common for one breast to be larger than the other." Slight asymmetry between breasts is normal and not a cause for concern unless there is a sudden change.
D. "I will perform breast exams the day my period begins": BSE should be done 5-7 days after the menstrual period starts when hormonal swelling has subsided.

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A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?

A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

A nurse is reinforcing teaching with a client who is to undergo a bone marrow aspiration. Which of the following statements should the nurse include in the teaching?

A nurse is transporting a client who has pneumonia and is on droplet precautions to radiology. Which of the following safety measures should the nurse take while transporting the client?

A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?

A nurse is collecting data from a client about her current pain status. Which of the following questions should the nurse ask to determine the quality of the client's pain?

A nurse is preparing to administer enoxaparin 1.5 mg/kg subcutaneously to a client who weighs 175 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)