A nurse should include which rationale when instructing a client to avoid sitting with knees crossed?

Decreases risk of skin breakdown behind the knee.

Eliminates pain of arthritis of the lower legs.

Prevents pressure on the popliteal artery.

Avoids irritation of the knee joints.

Answer and Explanation

The Correct Answer is C

The popliteal artery is a major blood vessel that runs behind the knee and supplies blood to the lower leg. Sitting with knees crossed can compress this artery and reduce blood flow to the leg.

This can cause numbness, tingling, or pain in the leg. It can also increase the risk of blood clots or varicose veins.

Choice A is wrong because sitting with knees crossed does not decrease the risk of skin breakdown behind the knee. In fact, it may increase the risk by causing friction or pressure on the skin.

Choice B is wrong because sitting with knees crossed does not eliminate the pain of arthritis in the lower legs.

Arthritis is a joint inflammation that causes pain, stiffness, and swelling. Sitting with knees crossed can worsen these symptoms by putting more stress on the knee joints.

Choice D is wrong because sitting with knees crossed does not avoid irritation of the knee joints.

On the contrary, it can cause irritation by overstretching the knee ligaments and muscles

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Correct Answer is B

Explanation

Ineffective protection related to chemotherapy side effects. This nursing diagnosis takes priority for a client who is receiving chemotherapy

treatment for cancer because chemotherapy can cause immunosuppression and increase the risk of infection, bleeding, and other complications.

According to the NANDA-I taxonomy, ineffective protection is defined as “decreased ability of an individual to guard the self from internal or external threats such as illness or injury” (NANDA International, 2018).

Choice A is wrong because situational low self-esteem related to job loss due to chemotherapy side effects is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can affect the client’s self-image and emotional well-being, it is not a life-threatening condition and can be addressed after ensuring the client’s safety and physiological needs.

Choice C is wrong because anticipatory grieving related to a cancer diagnosis is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although cancer can cause emotional distress and grief for the client and their family, it is not an immediate threat to the client’s health and can be managed with psychological support and counseling.

Choice D is wrong because fatigue related to cancer treatments is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can cause fatigue and weakness, it is not a critical condition and can be alleviated with rest, nutrition, and energy conservation strategies.

A. Does not complete the care plan for a newly admitted client before leaving the unit. B. Records a client’s refusal to take a prescribed medication on the chart. C. Contaminates and discards two indwelling catheters during the insertion procedure. D. Experiences back pain after moving a client up in the bed.

Correct Answer is C

Explanation

The nurse should complete an incident report when he or she contaminates and discards two indwelling catheters during the insertion procedure. This is because an incident report is a tool for documenting any event that is not consistent with the routine operation of a health care unit or the routine care of a client. An incident report helps to identify potential risks and improve quality and safety.

Choice A is wrong because not completing the care plan for a newly admitted client before leaving the unit is not an incident that requires reporting.

It is a matter of time management and prioritization.

Choice B is wrong because recording a client’s refusal to take prescribed medication on the chart is not an incident that requires reporting.

It is a part of the nursing documentation and communication.

Choice D is wrong because experiencing back pain after moving a client up in the bed is not an incident that requires reporting.

It is a personal injury that may be related to improper body mechanics or ergonomics.

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A nurse should include which rationale when instructing a client to avoid sitting with knees crossed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing diagnosis takes priority for a client who is receiving chemotherapy treatment for cancer?

Correct Answer is B

Explanation

Which situation requires a nurse to complete an incident report? The nurse:.

Correct Answer is C

Explanation

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