The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

Bends from the waist to pick trash off the floor.

Leans forward to pull a pan from a high shelf.

Locks knees while preparing food on the counter.

Widens stance while working near the sink.

Brings a heavy can close to body before lifting.

Answer and Explanation

Correct Answer : D,E

A.   Bending from the waist to pick up trash can cause imbalance and strain; it is safer to bend at the knees.

B.   Leaning forward to pull a pan from a high shelf can lead to loss of balance; using a step stool is safer.
C.   Locking the knees can lead to loss of balance and is not a recommended posture.

D. Widening the stance provides a stable base and helps maintain balance while working.
E. Bringing a heavy can close to the body before lifting uses proper body mechanics, reducing the risk of strain and promoting balance.

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Correct Answer is A

Explanation

A. Assessing the pin sites for signs of infection is essential in clients with skeletal traction to detect any early signs of infection, such as redness, swelling, warmth, or purulent drainage. Prompt identification and management of pin site infections can prevent complications.
B. Administering pain medication at designated intervals around the clock helps to ensure adequate pain control and comfort for the client. However, this intervention alone does not specifically address the care needs related to skeletal traction.
C. Assessing the pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this assessment is not directly related to the care of skeletal traction itself.
D. Removing traction every shift is not indicated unless there is a specific reason to do so as ordered by the healthcare provider. Continuous traction is often necessary for proper alignment and stabilization of the fracture. Additionally, providing skin care is important to prevent skin breakdown around the traction device, but removing traction every shift is not part of routine care.

A. Activated partial thromboplastin time (aPTT) is 2 times the control value. B. S3 heart sounds are present with auscultation. C. Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex. D. Guaiac test of the stools is positive.

Correct Answer is A

Explanation

A. An aPTT that is 2 times the control value indicates that the heparin is effectively anticoagulating the blood, which is a desired outcome in managing MI to prevent clot formation.
B. S3 heart sounds can indicate heart failure and are not a sign of a satisfactory response to MI treatment.
C. Wide Q waves indicate a previous infarction but do not reflect the immediate effectiveness of the treatment.
D. A positive guaiac test indicates gastrointestinal bleeding, which is a potential complication rather than a satisfactory response.

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The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

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Naxlex Comprehensive Predictor Exams

106 A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

Correct Answer is A

Explanation

A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

Correct Answer is A

Explanation

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