Nokea
A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply.
- A. Contact the clinic if any hot areas or foul odors develop in the cast
- B. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet
- C. Elevate the affected extremity above heart level for the first 48 hours
- D. Expect some numbness and tingling of the fingers during the first week
- E. Use only soft, padded objects to scratch the skin under the cast
Correct Answer: A,B,C,E
Rationale: Hot areas or odors (A) suggest infection, keeping the cast dry (B) prevents skin breakdown, elevation (C) reduces swelling, and soft objects (E) avoid injury. Numbness and tingling (D) are not normal and may indicate nerve compression, requiring immediate reporting.
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The client complains of frequent insomnia affecting her ability to rest well. Which of the following factors or lifestyle choices in her assessment history most likely contributes to her inability to sleep?
- A. Having a slight snack at bedtime
- B. Heart disease prevention of one baby aspirin each day
- C. Reading in bed prior to going to sleep
- D. Smoking 1½ packs of filtered cigarettes each day
Correct Answer: D
Rationale: Nicotine in cigarettes is a stimulant, disrupting sleep and likely contributing to insomnia, unlike snacks, aspirin, or reading.
The nurse is talking with a client with stable angina who has a prescription for sublingual nitroglycerin. Which of the following statements by the client would require follow-up?
- A. I shall sit down if possible before taking this medication to prevent dizziness.
- B. I may experience flushing or a headache when taking this medication.
- C. I will avoid taking the medication with grapefruit juice.
Correct Answer: C
Rationale: Nitroglycerin is not contraindicated with grapefruit juice (C), indicating a misunderstanding. Sitting down (A) prevents falls from hypotension, and flushing/headache (B) are expected side effects, both correct.
The nurse is floated from the obstetrical (OB) floor to the medical/surgical floor. Which client is the best assignment for the OB nurse?
- A. Female client with a fractured pelvis who is 4 months pregnant
- B. Female client with cytomegalovirus pneumonia
- C. Male client with an open bowel resection with a Foley catheter
- D. Male client with history of Billroth II surgery who is septic
Correct Answer: A
Rationale: The OB nurse’s expertise in pregnancy care makes the pregnant client with a fractured pelvis (A) the best assignment, as it aligns with their skills in managing maternal-fetal health. Other clients (B, C, D) require general medical-surgical care unrelated to OB.
The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply.
- A. Age of 50
- B. Diagnosis of ovarian cancer
- C. Lying pulse 80/min, standing pulse 110/min
- D. Osteoarthritis of knees
- E. Takes carbidopa/levodopa
- F. Uses a cane to ambulate
Correct Answer: C,D,E
Rationale: Orthostatic pulse change (C) indicates cardiovascular instability, increasing fall risk. Osteoarthritis of knees (D) impairs mobility and stability. Carbidopa/levodopa (E) for Parkinson’s can cause orthostatic hypotension or dyskinesia, heightening fall risk. Age 50 (A) is not a significant risk factor alone, ovarian cancer (B) is unrelated to falls, and cane use (F) reduces risk if used correctly.
The nurse is planning care for all of the following clients. Which client should be cared for first?
- A. A 60-year-old who is three days postop and needs a dressing change and ambulation
- B. A 75-year-old who had a suprapubic prostatectomy yesterday and says, 'Take that tube out of me, I have to pee.'
- C. A 90-year-old who had a total hip replacement two days ago and is to get out of bed today
- D. A 50-year-old who had an abdominal cholecystectomy yesterday and is asking for pain medication
Correct Answer: B
Rationale: The 75-year-old post-prostatectomy client's request to remove the catheter and urgency to urinate suggest potential catheter obstruction or bladder irritation, which could lead to complications like infection or bladder damage. This requires immediate assessment and intervention, taking priority over routine dressing changes, scheduled mobility, or pain management.