Nokea
A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to
- A. Promote the client's comfort
- B. Reduce the drying time
- C. Decrease irritation to the skin
- D. Improve venous return
Correct Answer: D
Rationale: Elevating the leg both improves venous return and reduces swelling. Client comfort will be improved as well.
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The doctor has ordered two medications to be given intramuscularly. The nurse should:
- A. Ask the doctor to clarify the order.
- B. Give one injection, wait 30 minutes, and give the other.
- C. Determine whether the medications can be combined.
- D. Administer the injections, one in each hip.
Correct Answer: C
Rationale: The nurse must check if the medications are compatible for combination in one syringe to minimize injections. Administering separately without checking or in specific sites is premature.
The nurse caring for a client with anemia recognizes which clinical manifestation as one specific for a hemolytic type of anemia?
- A. Jaundice
- B. Anorexia
- C. Tachycardia
- D. Fatigue
Correct Answer: A
Rationale: The destruction of red blood cells causes the release of bilirubin, leading to the yellow hue of the skin. Answers C and D occur with anemia but are not specific to hemolytic. Answer B does not relate.
The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
- A. Repeatedly checking that the door is locked
- B. Verbalized suspicions about thefts
- C. Preference for consistent caregivers
- D. Repetitive, involuntary movements
Correct Answer: A
Rationale: Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors, performed to reduce feelings of anxiety, often interfere with normal function and employment.
The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply.
- A. Allow the client to refuse food if not feeling hungry
- B. Ask if the client is experiencing any pain or nausea
- C. Involve the client in meal planning and food selection
- D. Plan for loved ones to share mealtimes with the client
- E. Provide oral care before and after meals to alleviate dry mouth
Correct Answer: A,B,D,E
Rationale: Allowing food refusal (A) respects autonomy, assessing pain/nausea (B) addresses barriers to eating, shared mealtimes (D) provide comfort, and oral care (E) improves appetite. Meal planning (C) may overwhelm a cachectic client.
A client with allergic rhinitis has an order for a long-acting nasal spray that contains oxymetazoline. The client should be instructed to use the spray as directed to prevent:
- A. Bleeding tendencies
- B. Increased nasal congestion
- C. Nasal polyps
- D. Tinnitus
Correct Answer: B
Rationale: Overuse of oxymetazoline can cause rebound nasal congestion (rhinitis medicamentosa). It does not typically cause bleeding, nasal polyps, or tinnitus.