Nokea
A client has had a recent below-knee (BK) amputation of the right leg because of a traumatic injury. After removing the elastic wrap, which the client had applied, the nurse notes an unusual pattern of swelling. Which of the following is the most likely reason for this observation?
- A. Wound infection
- B. Impaired circulation to the stump
- C. Incorrect wrap technique
- D. Bleeding into the tissues
Correct Answer: C
Rationale: An unusual swelling pattern after removing an elastic wrap suggests incorrect wrap technique (C), which can cause uneven pressure. Infection (A), impaired circulation (B), or bleeding (D) would present differently.
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The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
- A. prepare to administer IV fluids
- B. notify the health care provider
- C. order a mechanical soft diet for the client
- D. administer the next dose of lithium when it is due
- E. observe the client for confusion and slurred speech
Correct Answer: A, B, E
Rationale: A lithium level of 2.2 mEq/L indicates toxicity (therapeutic range: 0.6–1.2 mEq/L). The nurse should prepare IV fluids, notify the provider, and monitor for symptoms like confusion and slurred speech. A soft diet is unnecessary, and the next dose should be held.
A client has ataxia following a cerebral vascular accident. The nurse should:
- A. Supervise the client's ambulation
- B. Measure the client's intake and output
- C. Request a consult for speech therapy
- D. Provide the client with a magic slate
Correct Answer: A
Rationale: Ataxia impairs coordination, increasing fall risk, so supervising ambulation is essential for safety.
The nurse is assigned a male client with a long-term in-dwelling catheter for incontinence. The nurse plans on performing which of the following to prevent complications?
- A. perform perineal care using sterile technique
- B. irrigate daily with 60 cc normal saline
- C. restrict fluids to 1,500 cc/day
- D. stabilize the catheter on the abdomen
Correct Answer: D
Rationale: Stabilizing the catheter prevents traction and urethral trauma. Perineal care uses clean technique, routine irrigation is unnecessary, and fluid restriction is inappropriate.
A nurse is caring for an 84-year-old client who is malnourished. The nurse is concerned about all of the following complications of malnutrition EXCEPT
- A. increased risk for falls.
- B. poor wound healing.
- C. chronic heart failure.
- D. increased risk of infections.
Correct Answer: C
Rationale: Malnutrition increases fall risk, impairs wound healing, and raises infection risk due to weakened immunity. Chronic heart failure is not directly caused by malnutrition.
A client scheduled for a cardiac catheterization tells the nurse, 'My mother died during this same procedure 10 years ago. I'm afraid the same thing will happen to me.' Which of the following responses by the nurse is the most appropriate?
- A. It's normal to be scared. You are safe here. Let's discuss the procedure.
- B. I'll ask the cardiologist to come and speak with you about your concerns.
- C. We have the best outcomes of any facility in the area for this procedure.
- D. Don't worry. The procedure has improved a lot in the last 10 years.
Correct Answer: A
Rationale: Acknowledging the client’s fear and discussing the procedure provides reassurance and addresses concerns therapeutically.