Nokea
The nurse is caring for a client who has been placed in skin traction. Which action by the nurse provides for countertraction to reduce shear and friction?
- A. Using a footboard
- B. Providing an overhead trapeze
- C. Slightly elevating the foot of the bed
- D. Slightly elevating the head of the bed
Correct Answer: C
Rationale: The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in skin traction (which is applied to a leg), the foot of the bed is elevated. Option 3 provides a force that opposes the traction force effectively without harming the client. A footboard, an overhead trapeze, or elevating the head of the bed is not used to provide countertraction.
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A client prescribed lithium carbonate for the treatment of bipolar disorder has a medication blood level of 1.6 mEq/L (1.6 mmol/L). Which assessment question should the nurse ask to determine whether the client is experiencing signs of lithium toxicity associated with this level?
- A. Do you hear ringing in your ears?
- B. Have you noted that your vision is blurred?
- C. Have you fallen recently because you are dizzy?
- D. Have you been experiencing any nausea, vomiting, or diarrhea?
Correct Answer: D
Rationale: Normal lithium levels are between 0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L). One of the most common early signs of lower level lithium toxicity is gastrointestinal (GI) disturbances such as nausea, vomiting, or diarrhea. The assessment questions in options 1, 2, and 3 are related to the findings in lithium toxicity at higher levels.
The nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse should instruct mothers to take which action?
- A. If antibiotic ointment has been applied to the cord, it is not necessary to do anything else to it.
- B. All that is necessary is to wash the cord with antibacterial soap and allow it to air-dry once a day.
- C. Apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause pain to the newborn infant.
- D. Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day.
Correct Answer: D
Rationale: The cord and base should be cleansed with alcohol (or another substance as prescribed) thoroughly, two to three times per day. The steps are (1) lift the cord; (2) wipe around the cord, starting at the top; (3) clean the base of the cord; and (4) fold the diaper below the umbilical cord to allow the cord to air-dry and prevent contamination from urine. Antibiotic ointment is not normally prescribed. Continuation of cord care is necessary until the cord falls off within 7 to 14 days. Water and soap are not necessary; in fact, the cord should be kept from getting wet. The infant does not feel pain in this area.
The nurse is monitoring a client diagnosed with a ruptured appendix for signs of peritonitis. The nurse should assess for which manifestations of this complication? Select all that apply.
- A. Bradycardia
- B. Distended abdomen
- C. Subnormal temperature
- D. Rigid, boardlike abdomen
- E. Diminished bowel sounds
- F. Inability to pass flatus or feces
Correct Answer: B,D,E,F
Rationale: Peritonitis is an acute inflammation of the visceral and parietal peritoneum, the endothelial lining of the abdominal cavity. Clinical manifestations include distended abdomen; a rigid, boardlike abdomen; diminished bowel sounds; inability to pass flatus or feces; abdominal pain (localized, poorly localized, or referred to the shoulder or thorax); anorexia, nausea, and vomiting; rebound tenderness in the abdomen; high fever; tachycardia; dehydration from the high fever; decreased urinary output; hiccups; and possible compromise in respiratory status.
The nurse reviews a primary health care provider's prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Headache is a common side effect of nitrates.
- B. Fever usually accompanies myocardial infarction.
- C. Acetaminophen potentiates the therapeutic effect of nitrates.
- D. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
Correct Answer: A
Rationale: Headache occurs as a side effect of nitrates in many clients. Acetaminophen may be administered before nitrates to prevent headaches or minimize the discomfort from the headaches.
An assessment of a client's vocal cords requires indirect visualization of the larynx. Which instruction should the nurse give the client to facilitate this procedure?
- A. Try to swallow.
- B. Hold your breath.
- C. Breathe normally.
- D. Roll the tongue to the back of the mouth.
Correct Answer: C
Rationale: Indirect laryngoscopy is done to assess the function of the vocal cords or obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror, head mirror, and light source. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. Swallowing cannot be done with the mirror in place. The procedure takes longer than the time the client would be able to hold the breath, and this action is ineffective anyway. The tongue cannot be moved back because it would occlude the airway.