Nokea
The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
- A. Weak pedal pulses
- B. Drainage at the pin sites
- C. Complaints of leg discomfort
- D. Toes demonstrating a brisk capillary refill
Correct Answer: A
Rationale: Buck's traction is skin traction. Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. Skeletal (not skin) traction uses pins. Discomfort is expected. Warm toes with brisk capillary refill is a normal finding.
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The nurse is caring for a client who was recently admitted with a diagnosis of anorexia nervosa. When the nurse enters the room, the client is engaged in rigorous push-ups. Which nursing action should the nurse implement?
- A. Allowing the client to complete the exercise program
- B. Interrupting the client and weigh the client immediately
- C. Interrupting the client and offer to take the client for a walk
- D. Telling the client that he or she is not allowed to exercise rigorously
Correct Answer: C
Rationale: Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise, as well as place limits on rigorous activities. Allowing the client to complete the exercise program could be harmful. Weighing the client reinforces the altered self-concept that the client experiences and the client's need to control weight. Telling the client that he or she is not allowed to exercise rigorously will increase his or her anxiety.
The nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. Which finding should the nurse expect to note if this disorder was present?
- A. A dull red tympanic membrane
- B. A mobile tympanic membrane
- C. A transparent tympanic membrane
- D. A pearly colored tympanic membrane
Correct Answer: A
Rationale: Otoscopic examination of a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Options 2, 3, and 4 indicate normal findings in an otoscopic examination.
The nurse is assessing a client who is being treated with a beta-adrenergic blocker. Which assessment findings would indicate that the client may be experiencing dose-related side effects of the medication? Select all that apply.
- A. Dizziness
- B. Bradycardia
- C. Chest pain
- D. Reflex tachycardia
- E. Sexual dysfunction
- F. Cardiac dysrhythmias
Correct Answer: A,B,E
Rationale: Beta-adrenergic blockers, commonly called beta blockers, are useful in treating cardiac dysrhythmias, mild hypertension, mild tachycardia, and angina pectoris. Side effects commonly associated with beta blockers are usually dose related and include dizziness (hypotensive effect), bradycardia, hypotension, and sexual dysfunction (impotence). Options 3, 4, and 6 are reasons for prescribing a beta blocker; however, these are general side effects of alpha-adrenergic blockers.
A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which measure should the nurse implement to promote client safety?
- A. Use the right arm blood pressure measurement.
- B. Use the fistula for all venipunctures and intravenous infusions.
- C. Ensure that small clamps are attached to the AV fistula dressing.
- D. Assess the fistula for the presence of a bruit and thrill every 4 hours.
Correct Answer: D
Rationale: AV fistulas are created by anastomosis of an artery and a vein within the subcutaneous tissues to create access for hemodialysis. Fistulas should be evaluated for presence of thrills (palpate over the area) and bruits (auscultate with a stethoscope) as an assessment of patency. Blood pressures or venipunctures are not done on the extremity with the fistula because of the risk of clotting, infection, or damage to the fistula. The fistula is not used for venipunctures or intravenous infusions for the same reason. Clamps may be needed for an external device such as an AV shunt, but the AV fistula is internal.
The nurse is creating a plan of care for a client who has returned to the nursing unit after left nephrectomy. Which assessments should the nurse include in the plan of care? Select all that apply.
- A. Pain level
- B. Vital signs
- C. Hourly urine output
- D. Tolerance for sips of clear liquids
- E. Ability to cough and deep breathe
Correct Answer: A,B,C,E
Rationale: After nephrectomy, it is imperative to measure the urine output on an hourly basis. This is done to monitor the effectiveness of the remaining kidney and detect renal failure early, if it should occur. The client may also experience significant pain after this surgery, which could affect the client's ability to reposition, cough, and deep breathe. Therefore, the next most important measurements are vital signs, pain level, and ability to cough and deep breathe. Clear liquids are not given until the client has bowel sounds.