The nurse enters the room of an older adult client and observes the client positioned in a wheelchair as seen in the picture. The unlicensed assistive personnel (UAP) is preparing to push the client's wheelchair in the hallway. Which instruction should the nurse provide the UAP before the client is moved into the hallway?

Use a belt restraint to secure the client in the chair.

Empty the client's urinary drainage bag.

Reposition the client's urinary drainage bag.

Elevate the client's feet higher on the foot rests.

Answer and Explanation

The Correct Answer is C

A.   Using a belt restraint is generally not recommended unless specifically ordered for safety reasons, as it may not be appropriate or necessary in all cases. Restraints should only be used when absolutely needed and when all other methods of ensuring safety have been considered.
B.   Emptying the urinary drainage bag before moving the client is important to prevent overflows and ensure that the bag does not become a source of discomfort or potential infection. However, this step might not always be immediately necessary unless the bag is full or the client’s comfort and hygiene are at risk.
C.   Repositioning the urinary drainage bag is crucial for ensuring that the bag remains below the level of the bladder and is not subject to kinks or obstructions. This helps prevent backflow and potential infections. Proper positioning also contributes to the client’s comfort and dignity, making this a priority before moving the client.
D.   Elevating the client’s feet on the footrests is important for their comfort and to prevent swelling or pressure sores, especially if the client has limited mobility or circulatory issues. Proper positioning can prevent discomfort and promote better circulation, which is essential for maintaining the client’s well- being during transport.

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Correct Answer is C

Explanation

A. Tilting the pelvis forwards and backwards involves movements of the pelvic girdle, which is more related to the actions of the hip joints and lumbar spine, rather than hinge joints specifically. This action involves the pelvic tilt and is not an exercise for hinge joints like the elbow or knee.
B. Turning the head to the right and left involves rotation of the cervical spine and is associated with pivot joints rather than hinge joints. This action does not involve flexion and extension typical of hinge joints, which are primarily the elbow and knee.
C. This action involves bending the arm at the elbow joint, which is a classic example of a hinge joint. The elbow allows for flexion (bending) and extension (straightening) movements, making it a key example of a hinge joint. This is the correct action for exercising hinge joints.
D. Extending the arm and rotating in circles involves movements of the shoulder joint, which is a ball- and-socket joint, not a hinge joint. The shoulder joint allows for a wide range of movements including circumduction, which is different from the simple flexion and extension movements of hinge joints.

A. Reposition the dropper. B. Pull the auricle up and out. C. Visualize the ear drum. D. Administer the ear drops.

Correct Answer is B

Explanation

A. The dropper should already be positioned correctly, with the tip pointing toward the ear canal.
B. For adolescents and adults, the auricle (outer ear) should be pulled up and out to straighten the ear canal. This allows the ear drops to flow directly into the ear canal, avoiding the tympanic membrane (eardrum). Correctly positioning the auricle helps to prevent irritation and discomfort during ear drop administration.
C. While visualizing the eardrum is important for certain procedures, it's not necessary when administering ear drops.
D. The ear drops should be administered after the auricle is pulled up and out to ensure proper placement in the ear canal.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Correct Answer is C

Explanation

The nurse prepares to instill an adolescent client's ear drops as seen in the picture. Which should the nurse do next?

Correct Answer is B

Explanation

An older adult woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Select all that apply.

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?