Nokea
A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?
- A. Remove one of the weights.
- B. Tie knots in the ropes near the pulleys to shorten them.
- C. Increase the elevation of the affected extremity.
- D. Reapply the weights to ensure proper traction.
Correct Answer: D
Rationale: The correct answer is D: Reapply the weights to ensure proper traction. When the weights are resting on the floor, it means that there is no longer effective traction on the affected limb. To maintain proper skeletal traction, the weights should be suspended freely in the air. By reapplying the weights and ensuring they are hanging freely, the nurse can restore the necessary traction force to immobilize the fractured bone and facilitate healing. Removing a weight (choice A) may compromise the traction. Tying knots in the ropes (choice B) may alter the mechanics of the traction system. Increasing the elevation of the extremity (choice C) does not address the issue of the weights resting on the floor.
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A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
- A. Level of consciousness
- B. Surgical site
- C. Pain level
- D. Respiratory status
Correct Answer: D
Rationale: The correct answer is D: Respiratory status. In the PACU, ensuring adequate oxygenation and ventilation is crucial for the client's immediate postoperative recovery. Monitoring respiratory status helps prevent complications like hypoxia or respiratory distress. Assessing the airway, breathing rate, depth, and oxygen saturation takes precedence over other assessments. Level of consciousness (A) is important but can be affected by respiratory issues. Surgical site (B) assessment is important but not an immediate priority. Pain level (C) is important but can be managed once respiratory status is stable. Summary: Respiratory status is the priority as it directly impacts the client's immediate well-being and recovery.
A nurse is providing teaching to a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching?
- A. Take stimulant laxatives daily to relieve constipation.
- B. Avoid fiber-rich foods to prevent bloating.
- C. Increase water intake and use bulk-forming laxatives.
- D. Eat a low-carbohydrate diet to reduce symptoms.
Correct Answer: C
Rationale: Correct Answer: C. Increase water intake and use bulk-forming laxatives.
Rationale: Increasing water intake helps soften stool, easing constipation in IBS-C. Bulk-forming laxatives add fiber to stool, improving bowel movements. Stimulant laxatives (A) can lead to dependency. Avoiding fiber-rich foods (B) worsens constipation. A low-carbohydrate diet (D) may exacerbate constipation.
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take?
- A. Maintain low intermittent suction.
- B. Clamp the NG tube every 2 hours.
- C. Remove the NG tube immediately.
- D. Encourage high-fiber foods.
Correct Answer: A
Rationale: The correct answer is A: Maintain low intermittent suction. This is because in a small bowel obstruction, the NG tube helps decompress the bowel by removing gastric contents and relieving pressure. Low intermittent suction helps prevent excessive suction which can cause tissue damage.
Clamping the NG tube every 2 hours (choice B) is incorrect as it will prevent the tube from effectively decompressing the bowel. Removing the NG tube immediately (choice C) is also incorrect as it is needed for decompression. Encouraging high-fiber foods (choice D) is contraindicated as they can worsen the obstruction.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an excess of carbon dioxide (CO2) in the blood, leading to a decrease in pH. This imbalance occurs when the lungs are unable to eliminate enough CO2 through respiration, causing it to accumulate in the bloodstream. This excess CO2 combines with water in the blood to form carbonic acid, leading to acidosis. Choices B, C, and D are incorrect as they do not directly relate to the accumulation of CO2 in respiratory acidosis. Loss of bicarbonate (B) would lead to metabolic acidosis, excessive vomiting (C) would cause metabolic alkalosis, and hyperventilation (D) would actually help in decreasing CO2 levels, which is not the case in respiratory acidosis.
A nurse is caring for a client who has COPD. Which of the following findings require immediate follow-up?
- A. Client is oriented to person, place, and time.
- B. Client is restless.
- C. Pupils are reactive to light.
- D. Client is tachypneic, cough is productive, and mucous is yellow in color.
- E. Wheezes and crackles heard upon auscultation.
Correct Answer: D
Rationale: The correct answer is D. Tachypnea, productive cough with yellow mucus in a client with COPD indicate a potential exacerbation requiring immediate follow-up. Tachypnea suggests respiratory distress, while yellow mucus may indicate infection. Prompt intervention can prevent worsening respiratory status. Choices A, B, and C do not indicate acute respiratory distress. Option E may be concerning but doesn't necessitate immediate intervention like option D does.