Nokea
A 12-year-old boy has a fractured femur and is immobilized in traction as shown in the fi gure. The nurse should:
- A. Add additional weight until the foot is only 2 inches from the bed.
- B. Offer foods that are easy to eat.
- C. Place a pillow under the fractured leg to provide support.
- D. Provide opportunities for age-appropriate activities.
Correct Answer: D
Rationale: The traction is set up correctly. Additional weights are not needed. A well-balanced diet with fiber should be offered. A pillow under the leg would negate the effects of the traction. Because the adolescent is positioned this way for an extended period, the nurse can help by fi nding activities that interest the client.
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In preparing a plan of care, which is the priority intervention to address the needs of a client recently assaulted sexually?
- A. Providing instructions for medical follow-up
- B. Obtaining appropriate counseling for the victim
- C. Providing anticipatory guidance for police investigations, medical questions, and court proceedings
- D. Exploring safety concerns by obtaining permission to notify significant others who can provide shelter
Correct Answer: D
Rationale: After the provision of medical treatment, the nurse's next priority would be obtaining support and planning for safety. Option 1 is concerned with ensuring that the victim understands the importance of and commits to the need for medical follow-up. From the options provided, this is not a priority intervention. Options 2 and 3 seek to meet the emotional needs related to the rape and emotional readiness for the process of discovery and legal action.
The client scheduled for a transurethral resection prostatectomy (TURP) asks the nurse to explain how the prostate is going to be removed. The nurse should tell the client that the prostate will be removed through which pathway?
- A. The urethra
- B. A lower abdominal incision
- C. An upper abdominal incision
- D. An incision made in the perineal area
Correct Answer: A
Rationale: A TURP is done through the urethra. An instrument called a resectoscope is used to remove the tissue using high-frequency current. A lower abdominal incision is used for suprapubic or retropubic prostatectomy. An upper abdominal incision is not used. An incision between the scrotum and anus is made when a perineal prostatectomy is performed.
The nurse is caring for a client post-laparoscopic cholecystectomy. Which discharge instruction is most important?
- A. Resume normal diet immediately
- B. Report fever or yellowing of skin
- C. Avoid bathing for 2 weeks
- D. Lift heavy objects as tolerated
Correct Answer: B
Rationale: Fever or jaundice post-cholecystectomy may indicate complications like infection or bile duct injury, requiring immediate reporting.
Which statement about referrals is accurate?
- A. Referrals complement the healthcare teams' abilities to provide optimal care to the client.
- B. Referrals simply allow the client to be discharged into the community with the additional care they need.
- C. Nurses facilitate referrals to only the resources within the facility.
Correct Answer: A
Rationale: Referrals enhance the healthcare team's ability to provide comprehensive care by connecting clients to specialized services, not limited to discharge or internal resources .
The nurse is caring for a preterm neonate in the NICU. Which intervention is essential to prevent retinopathy of prematurity?
- A. Monitor oxygen saturation
- B. Administer vitamin D
- C. Provide high-calorie formula
- D. Keep the incubator at 37°C
Correct Answer: A
Rationale: Excessive oxygen can contribute to retinopathy of prematurity in preterm neonates. Monitoring oxygen saturation ensures levels remain within a safe range.