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?
Tilt the pelvis forwards and backwards.
Turn the head to the right and left.
Bend the arm by flexing the ulnar to the humerus.
Extend the arm at the side and rotate in circles.
The Correct Answer is C
Choice A rationale
Tilting the pelvis forwards and backwards exercises the pelvic joints, not the hinge joints.
Choice B rationale
Turning the head to the right and left exercises the neck joints, not the hinge joints.
Choice C rationale
Bending the arm by flexing the ulnar to the humerus exercises the hinge joints, such as the elbow, which is a hinge joint.
Choice D rationale
Extending the arm at the side and rotating in circles exercises the shoulder joint, which is a ball-and-socket joint, not a hinge joint.
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Correct Answer is C
Explanation
Choice A rationale
Advising the UAP to wear a standard face mask to obtain vital signs and then get fitted for a filter mask before providing personal care is not appropriate. The UAP should be properly equipped with the correct protective gear before any contact with the client.
Choice B rationale
Instructing the UAP that a standard face mask is sufficient to provide care for the assigned client is incorrect. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.
Choice C rationale
Sending the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N953.
Choice D rationale
Before changing assignments, determining which staff members have fitted particulate filter masks is prudent but not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.
Correct Answer is B
Explanation
Choice A rationale
Reporting any change in urine color is not a priority intervention for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The focus should be on comfort measures.
Choice B rationale
Keeping mucous membranes moist is essential for comfort in terminally ill clients who are mouth breathing and refusing fluids. This can be achieved by offering ice chips, sips of water, or using a moist cloth.
Choice C rationale
Recording the client’s daily weight is not a priority in this situation as the client is terminally ill and the focus should be on comfort rather than monitoring weight.
Choice D rationale
Maintaining the client in high Fowler’s position is not necessary unless it helps with breathing. The priority is to keep the client comfortable.