Nokea
A nurse is caring for a client who is in skin traction. Which of the following actions should the nurse take?
- A. Ensure the weights hang freely from the bed.
- B. Inspect the client's skin every 12 hours for signs of breakdown.
- C. Loosen the ropes of the pulleys when repositioning the client in bed.
- D. Maintain 6.8 kg (15 lb) of weight for the skin traction.
Correct Answer: A
Rationale: Ensuring weights hang freely (A) maintains proper traction alignment, critical for effectiveness.
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A nurse is caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take?
- A. Immobilize the client's fingers using a hand splint.
- B. Position the fractured arm below the level of the client's heart.
- C. Use a hair dryer to blow cool air into the cast to relieve itching.
- D. Perform neurovascular checks of the affected extremity every 2 hours.
Correct Answer: D
Rationale: Neurovascular checks (D) every 2 hours monitor circulation and nerve function post-cast.
A nurse is reinforcing teaching with the partner of a client who has contact precautions in place for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements by the client's partner indicates an understanding of the teaching?
- A. I can reuse unsoiled gloves when I re-enter the room.
- B. I will wear a gown when I help my partner take a bath.
- C. I can take my partner outside of the room as long as they wear a mask.
- D. I will wash my hands as soon as I leave the room.
Correct Answer: D
Rationale: Washing hands upon leaving (D) prevents MRSA spread, showing the partner understands contact precautions.
A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?
- A. Having a total cholesterol level below 200 mg/dL increases my risk for a stroke.
- B. My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke.
- C. I can decrease my risk for a stroke by losing excess weight.
- D. My risk for a stroke increases if my HbA1c level is 6 percent or less.
Correct Answer: C
Rationale: Losing excess weight (C) reduces stroke risk by improving cardiovascular health, indicating correct understanding.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following pieces of information should the nurse include in the plan of care?
- A. Monitor the client for weight loss.
- B. Inform the client of the adverse effect of diarrhea.
- C. Check the client for increased hypopigmentation under the patch.
- D. Advise the client about increased dry mouth.
Correct Answer: D
Rationale: Advising about dry mouth (D) is correct as it's a common side effect of clonidine, preparing the client for management.
A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching?
- A. Isolate for 24 hours after lesions appear.
- B. Place on airborne precautions.
- C. Administer a broad-spectrum antibiotic.
- D. Avoid direct contact.
Correct Answer: D
Rationale: Avoiding direct contact (D) prevents the spread of tinea corporis, a fungal infection, per the teaching.