Nokea
A client has a Pearson attachment on the traction setup. What is the purpose of this attachment?
- A. To support the lower portion of the leg.
- B. To support the thigh and upper leg.
- C. To allow attachment of the skeletal pin.
- D. To prevent flexion deformities in the ankle and foot.
Correct Answer: A
Rationale: The Pearson attachment supports the lower leg, maintaining alignment in balanced suspension traction.
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As part of the client's discharge planning after a subtotal gastrectomy, the nurse has identified Imbalanced nutrition: Less than body requirements as a major nursing diagnosis. To help the client meet nutritional goals at home, the nurse should develop a plan of care that includes which of the following interventions?
- A. Instruct the client to increase the amount eaten at each meal.
- B. Encourage the client to eat smaller amounts more frequently.
- C. Explain that if vomiting occurs after a meal, nothing more should be eaten that day.
- D. Inform the client that bland foods are typically less nutritional and should be used minimally.
Correct Answer: B
Rationale: Smaller, frequent meals help prevent dumping syndrome and ensure adequate nutrition post-gastrectomy. Large meals, fasting after vomiting, or avoiding bland foods are not appropriate.
Initial treatment for a cerebrospinal fluid (CSF) leak after transsphenoidal hypophysectomy would most likely involve:
- A. Repacking the nose.
- B. Returning the client to surgery.
- C. Enforcing bed rest with the head of the bed elevated.
- D. Administering high-dose corticosteroid therapy.
Correct Answer: C
Rationale: Bed rest with head elevation reduces pressure on the surgical site, promoting healing of a CSF leak.
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client?
- A. Keeping the client flat on one side or the other.
- B. Elevating the head of the bed to 30 degrees.
- C. Logrolling or turning as a unit when turning.
- D. Keeping the neck in a neutral position.
Correct Answer: A
Rationale: Keeping the client flat is contraindicated after a posterior fossa craniotomy, as it increases ICP. Elevating the head, logrolling, and neutral neck positioning promote venous drainage and spinal alignment, reducing ICP risk.
The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should:
- A. Use a fluorescent light source to assess the skin.
- B. L rescued the skin only when the Braden score is above 12.
- C. Look for skin color that is darker than the surrounding tissue.
- D. Avoid touching the skin during inspection.
Correct Answer: C
Rationale: In dark skin, Stage I pressure ulcers appear as darker areas compared to surrounding tissue, due to persistent redness or discoloration.
A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL and a serum potassium level of 3.5 mEq. The physician has ordered 1,000 mL 5% dextrose in water to be infused every 8 hours. Prior to implementing the physician orders, the nurse should contact the physician, explain the situation, provide background information, report the current assessment of the client, and:
- A. Suggest adding potassium to the fluids.
- B. Request an increase in the volume of intravenous fluids.
- C. Verify the order for 5% dextrose in water.
- D. Determine if the client should be placed in isolation.
Correct Answer: C
Rationale: 5% dextrose in water is inappropriate for a hyperglycemic client (325 mg/dL), as it may worsen hyperglycemia. The nurse should verify the order, likely suggesting normal saline instead.