Nokea
A client has a fractured jaw sustained in an automobile accident and has had the fracture surgically reduced and immobilized with a wire loop. What should the nurse ensure is present at the client's bedside in case of vomiting?
- A. Wire cutters
- B. A tracheostomy tray
- C. Ice water with a straw
- D. An antiemetic medication
Correct Answer: A
Rationale: Ensure that wire cutters are easily accessible at the client's bedside. The nurse should be familiar with how to cut wire loops if the client vomits or chokes. A tracheostomy tray is not necessary when an airway can be obtained by cutting the wires so the client does not aspirate. If vomiting occurs, the client should have nothing by mouth. Antiemetic medication should be administered prior to the client vomiting and should not be kept at the bedside.
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The nurse is assigned to care for a client who has had a total knee arthroplasty yesterday. What type of pharmacologic therapy does the nurse anticipate administering to this client to prevent complications related to the surgery?
- A. Antidysrhythmic therapy
- B. Antianginal therapy
- C. Antineoplastic therapy
- D. Anticoagulation therapy
Correct Answer: D
Rationale: Anticoagulation therapy and early ambulation are very important for clients who have knee or hip replacement to prevent thrombus formation. The other therapies are not indicated for the knee or hip arthroplasty.
A client sustained a stable fracture of the cervical spine and is having skeletal traction applied. What type of traction does the nurse educate the client about?
- A. Kirschner wires
- B. Thomas splint
- C. Steinmann pins
- D. Crutchfield tongs
Correct Answer: D
Rationale: Crutchfield tongs are used for skeletal traction in the case of a cervical spine fracture to stabilize the spine and maintain alignment. Kirschner wires and Steinmann pins are typically used for skeletal traction in other areas, such as limbs. A Thomas splint is used for femoral fractures and is a form of skin traction, not skeletal traction.
A client has a cast that extends from below the elbow to the palmar crease and is secured around the base of the thumb. The thumb is also casted. The nurse identifies this as which type of cast?
- A. Short arm cast
- B. Gauntlet cast
- C. Body cast
- D. Spica cast
Correct Answer: B
Rationale: A gauntlet cast is a short arm cast that extends from below the elbow to the palmar crease and is secured around the base of the thumb, with the thumb also being casted. A short arm cast extends from below the elbow to the palmar crease and is secured around the base of the thumb. A body cast is a larger form of a cylinder cast that encircles the trunk from about the nipple line to the iliac crests. A hip spica cast surrounds one or both legs and the trunk.
The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician?
- A. Blood pressure of 140/90 mm Hg
- B. Crackles in the lung bases
- C. SUBJECT: Client complains of pain in the affected rib area when taking a deep breath
- D. Heart rate of 94 beats/minute
Correct Answer: B
Rationale: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.
During the assessment of a client scheduled for orthopedic surgery, the nurse discovers that the client was previously treated for the disorder. In such a case, what additional data need to be collected?
- A. Occurrence of complications or problems during treatment
- B. Measures taken to minimize postoperative wound infection
- C. Perception of the client about the previous treatment
- D. Details of the medical team that handled the previous treatment
Correct Answer: A
Rationale: If the same disorder has been treated earlier, the nurse needs to determine and document any complications or problems that occurred during treatment. The nurse can determine whether the client understands the treatment or not based on the measures taken by the client to minimize postoperative wound infection. However, this factor can be assessed later because the nurse needs to explain the new treatment to the client. Although the client's perceptions of the previous treatment may be helpful, this data would not be as important. In addition, the nurse does not need to get details about the medical team that handled the previous treatment, unless specifically asked to do so.