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Questions 148

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Question 1 of 5

The nurse is caring for a 72-year-old female who must remain on bed rest after a hip fracture. The client has become confused and disoriented over the past 2 days. Which of the following is the best nursing intervention?

Correct Answer: A

Rationale: Familiar objects like photos, clocks, and calendars help reorient a confused client, reducing disorientation safely. Restraints are a last resort, and the other options are less effective.

Question 2 of 5

The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:

Correct Answer: A

Rationale: Prone positioning helps stretch hip flexors, preventing contractures after AKA by maintaining proper alignment.

Question 3 of 5

A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?

Correct Answer: D

Rationale: Tucking a diaper beneath the cast at the perineal opening helps keep the cast clean and prevents skin irritation.

Question 4 of 5

A nursing instructor demonstrates to several students how to wrap an amputated limb in a bandage using a figure eight technique. Which of the following correctly states the benefits of this technique? Select all that apply.

Correct Answer: B,C

Rationale: The figure-eight technique reduces swelling (
B) by promoting venous return and minimizes pain (
C) by stabilizing the limb. It does not prevent clots (
A) or air exposure (
D).

Question 5 of 5

The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has:

Correct Answer: B

Rationale: A pH of 7.47 and PCO2 of 28 indicate respiratory alkalosis, likely due to hyperventilation from the head injury.

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