MCD I Clinical Day 4 NCLEX Questions,100% CORRECT

The nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after having hip surgery. Which physical factors place the client at risk for injury in the home? S ...

The nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after having hip surgery. Which physical factors place the client at risk for injury in the home? Select all that apply. 1. A night-light in the bathroom 2. Elevated toilet seat with armrests 3. Cooking equipment such as a stove 4. Smoke and carbon monoxide detectors 5. A low thermostat setting on the water heater 6. Common household objects such as a doormat The nurse is teaching a client with cardiomyopathy about home care safety measures. Which most important instruction should the nurse provide? 1. Reporting pain 2. Taking vasodilators 3. Avoiding over-the-counter medications 4. Moving slowly from a sitting to a standing position A client who is 85 years old had an open reduction with internal fixation (ORIF) for a hip fracture 4 days ago. What should the nurse implement to provide safe care? 1. Provide ice chips instead of drinking water. 2. Instruct the client to call for help before getting up. 3. Minimize opioid administration to prevent dizziness. 4. Tell the client to roll to the affected side first before getting up The nurse is assessing a client who has just been measured and fitted for crutches. How will the nurse determine if the client’s crutches are fitted correctly? 1. The top of the crutch is even with the axilla. 2. The elbow is straight when the hand is on the handgrip. 3. The client’s axilla is resting on the crutch pad during ambulation. 4. The elbow is at a 30-degree angle when the hand is on the handgrip. HEALTH PROMOTION AND MAINTENANCE The nurse is teaching a client who is preparing for discharge from the hospital after a total hip replacement. Which statement by the client would indicate the need for further teaching? 1. “I cannot drive a car for probably 6 weeks.” 2. “I should not sit in one position for more than 4 hours.” 3. “I need to wear a support stocking on my unaffected leg.” 4. “I need to place a pillow between my knees when I lie down.” The nurse is working at an osteoporosis screening clinic and is interviewing and performing physical assessments on women. Which clients are at greatest risk for developing osteoporosis? Select all that apply. 1. An Asian woman 2. A large-boned, dark-skinned woman 3. A client who started menopause early 4. A client with a family history of the disease 5. A client who has a physically active lifestyle 6. A client with an inadequate intake of calcium and vitamin D PSYCHOSOCIAL INTEGRITY A client with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea– anxiety– dyspnea cycle? 1. Guided imagery and limiting fluids 2. Relaxation and breathing techniques 3. Biofeedback and coughing techniques 4. Distraction and increased dietary carbohydrates A client who has never been hospitalized before, who is in a hospital room with a roommate, is having trouble initiating the stream of urine. Knowing that there is no pathological reason for this difficulty, what nursing interventions should be included when assisting the client? Select all that apply. 1. Catheterizing the client 2. Running tap water in the sink 3. Assisting the client to a commode behind a closed curtain 4. Instructing the client to pour warm water over the perineum 5. Closing the bathroom door and instructing the client to pull the call bell when done PHYSIOLOGICAL INTEGRITY The nurse is performing range-of-motion (ROM) exercises on a client when the client unexpectedly develops spastic muscle contractions. Which interventions should the nurse implement? Select all that apply. 1. Stop movement of the affected part. 2. Massage the affected part vigorously. 3. Notify the health care provider immediately. 4. Force movement of the joint supporting the muscle. 5. Ask the client to stand and walk rapidly around the room. 6. Place continuous gentle pressure on the muscle group until it relaxes A home care nurse assesses an older client’s functional status and ability to perform activities of daily living (ADLs). What is the focus area of the nurse’s assessment? 1. Everyday routines 2. Self-care activities 3. Household management 4. Endurance and flexibility