Nokea
A client has his leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment?
- A. Inability to move toes.
- B. Cyanosis of toes.
- C. Complaints of cast tightness.
- D. Tingling of toes.
Correct Answer: D
Rationale: Tingling is an early sign of circulatory impairment due to nerve compression from swelling or tight casting, requiring prompt attention.
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A client with chronic kidney disease prescribed a protein restrictive diet should be instructed by the nurse to select which incomplete protein option for inclusion in her or his diet? Select all that apply.
- A. Fish
- B. Eggs
- C. Milk
- D. Nuts
- E. Grains
Correct Answer: D,E
Rationale: The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are incomplete proteins with the highest biological value. Nuts and grains are the only options that are not complete proteins. Foods such as meat, fish, milk, and eggs are complete proteins, which are not recommended for the client with chronic kidney disease.
An older client has been prescribed casanthranol on a long-term basis to treat constipation. The nurse determines that which laboratory finding is a result of the side/adverse effects of this medication?
- A. Sodium 135 mEq/L (135 mmol/L)
- B. Sodium 145 mEq/L (145 mmol/L)
- C. Potassium 3.1 mEq/L (3.1 mmol/L)
- D. Potassium 5.0 mEq/L (5.0 mmol/L)
Correct Answer: C
Rationale: Hypokalemia can result from long-term use of casanthranol, which is a laxative. The medication stimulates peristalsis and alters fluid and electrolyte transport, thus helping fluid to accumulate in the colon. The normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal range for sodium is 135 to 145 mEq/L (135 to 145 mmol/L). The remaining options all suggest normal values.
You have collected, aggregated and analyzed data which reflects the frequency of your staff returning medical equipment to the appropriate department because the staff members thought it was too unsafe to use. After the experts in the medical equipment inspect and test the equipment they report back to you, as the nurse manager, whether or not the equipment was indeed unsafe. This data indicates that 83% of the returns that were made by your staff were deemed safe and operable. What should you do?
- A. Counsel the staff about their need to stop wasting the resources of this department.
- B. Check the equipment yourself to determine the accuracy of this equipment department.
- C. Ignore it because everyone can make an innocent mistake.
- D. Plan an educational activity about determining what equipment to send for repairs.
Correct Answer: D
Rationale: The high rate of unnecessary returns (83% safe equipment) indicates a knowledge deficit among staff about assessing equipment safety. Planning an educational activity addresses this issue effectively.
In preparing a plan of care, which is the priority intervention to address the needs of a client recently assaulted sexually?
- A. Providing instructions for medical follow-up
- B. Obtaining appropriate counseling for the victim
- C. Providing anticipatory guidance for police investigations, medical questions, and court proceedings
- D. Exploring safety concerns by obtaining permission to notify significant others who can provide shelter
Correct Answer: D
Rationale: After the provision of medical treatment, the nurse's next priority would be obtaining support and planning for safety. Option 1 is concerned with ensuring that the victim understands the importance of and commits to the need for medical follow-up. From the options provided, this is not a priority intervention. Options 2 and 3 seek to meet the emotional needs related to the rape and emotional readiness for the process of discovery and legal action.
A client with a history of heart failure is prescribed torsemide (Demadex). The nurse should monitor the client for which of the following adverse effects?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypermagnesemia.
- D. Hypercalcemia.
Correct Answer: A
Rationale: Torsemide, a loop diuretic, can cause hypokalemia.