Nokea
A client comes to the emergency room with complaints of 'numbness, tingling, and coldness' of her left leg. She is able to walk. You note that the skin appears pale and is cool to the touch. What should the nurse do first?
- A. Ask if she had had a similar condition in her arms or the other leg
- B. Notify the physician immediately
- C. Obtain a detailed nursing health history
- D. Palpate and record the femoral, popliteal, posterior tibial, and dorsalis pedis pulses in the affected leg
Correct Answer: D
Rationale: Palpating pulses assesses for arterial occlusion, the priority to determine the cause of numbness and coldness, guiding urgent intervention.
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The nurse is administering alendronate (Fosamax) to an adult. Which instruction is necessary to give the client?
- A. Take medication with milk and a snack.
- B. Take medication after each meal.
- C. Sit up for at least 30 minutes after taking medication.
- D. Lie down for 30 minutes after taking medication.
Correct Answer: C
Rationale: Alendronate can cause esophageal irritation; sitting up for 30 minutes post-dose ensures proper passage and absorption, preventing reflux. Milk, meals, or lying down increase irritation risk.
The nurse is making a home visit for a client with an abdominal wound.
When irrigating the draining wound with a sterile saline solution, which of the following sequences would be MOST appropriate for the nurse to follow?
- A. Pour the solution, wash hands, and remove the soiled dressing.
- B. Wash hands, prepare the sterile field, and remove the soiled dressing.
- C. Prepare the sterile field, put on sterile gloves, and remove the soiled dressing.
- D. Remove the soiled dressing, flush the wound, and wash hands.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) hands should be washed first (2) correct-handwashing should be done prior to beginning any procedure, especially irrigating a wound (3) using sterile gloves to remove the dressing would contaminate them (4) hands should be washed first
A client whose father died from Huntington's chorea asks what the chances are that he will develop the disease. The nurse knows that the chances of the client developing the disease are:
- A. 25%
- B. 50%
- C. 100%
- D. 0%
Correct Answer: B
Rationale: Huntington's disease is autosomal dominant; with one affected parent, the client has a 50% chance of inheriting the gene and developing the disease.
The nurse is providing home care to a postoperative client who has a wound infection. What is essential to include when teaching the family about infection transmission?
- A. The client should stay isolated from the rest of the family.
- B. No one who is pregnant should care for the client.
- C. The family should wash hands before and after caring for the client.
- D. The client should not be allowed to have any visitors.
Correct Answer: C
Rationale: Hand washing before and after care is critical to prevent infection transmission. Isolation, restricting pregnant caregivers, or banning visitors are not necessary unless specified.
The nurse on postpartum is preparing four clients for discharge. It would be MOST important for the nurse to refer which of the following clients for homecare?
- A. A 15-year-old who vaginally delivered a 7-lb male two days ago.
- B. An 18-year-old multipara who delivered a 9-lb female by cesarean section two days ago.
- C. A 20-year-old multipara who delivered 1 day ago and is complaining of cramping.
- D. A 22-year-old who delivered by cesarean section and is complaining of burning on urination.
Correct Answer: D
Rationale: Burning on urination suggests a urinary tract infection, requiring homecare follow-up. Options A, B, and C are routine postpartum findings.