Nokea
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
- A. Bleeding, bruising, and hemorrhage
- B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
- C. Pain, pallor, pulselessness, paresthesia, and paralysis
- D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
Correct Answer: C
Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
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The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:
- A. Mix the insulin with Dextrose 5% in water.
- B. Flush the IV tubing with the insulin solution and discard the first 50 mL.
- C. Give the insulin without diluting.
- D. Add the insulin to a solution of normal saline.
Correct Answer: D
Rationale: Regular insulin for IV infusion should be diluted in normal saline to ensure compatibility and prevent adsorption to IV tubing. Dextrose is inappropriate during DKA, and flushing with insulin wastes medication.
Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?
- A. Circle the surgical site with a marker.
- B. Verify patient information with a designated patient representative.
- C. Designate operative site with a facility designated mark.
- D. Include a copy of the Advanced Directives on the chart before surgery.
- E. Verify patient information three times.
- F. Observe pre-op time out before proceeding with surgery.
Correct Answer: C, E, F
Rationale: Joint Commission protocols include marking the site with a facility-designated mark (C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (A) is not standard. Patient representative verification (B) and advance directives (D) are not part of site verification.
The local health clinic recommends vaccination against influenza for all its employees. The influenza vaccine is usually given annually in:
- A. November
- B. December
- C. January
- D. February
Correct Answer: A
Rationale: Influenza vaccines are typically administered in November, before the peak flu season, to ensure immunity during winter months.
A client with a history of a deep vein thrombosis is receiving Warfarin (Coumadin). The nurse should teach the client to avoid:
- A. Green leafy vegetables
- B. Dairy products
- C. Citrus fruits
- D. High-fat foods
Correct Answer: A
Rationale: Green leafy vegetables are high in vitamin K, which antagonizes warfarin’s anticoagulant effect. Dairy, citrus, and high-fat foods do not significantly affect warfarin.
After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:
- A. Suicide
- B. Exacerbation of depressive symptoms
- C. Violence toward others
- D. Psychotic behavior
Correct Answer: A
Rationale: When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. Improvement in behavior is not indicative of an exacerbation of depressive symptoms. The depressed client has a tendency for self-violence, not violence toward others. Depressive behavior is not always accompanied by psychotic behavior.