Nokea
A client is admitted with a fractured right hip. The doctor writes an order for Buck's traction. Which of the following actions, if taken by the nurse, is MOST important?
- A. Turn the client every two hours to the unaffected side.
- B. Maintain the client in a supine position.
- C. Encourage the client to use a bedside commode.
- D. Placing a footboard on the bed.
Correct Answer: A
Rationale: immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side
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A client comes to the nurse's station for her antipsychotic medication. The nurse notes that the client has torticollis, an arched back, and rapid movement of the eyes.
Which of the following action should the nurse take FIRST?
- A. Determine what other medications the patient is taking.
- B. Perform a neurological assessment.
- C. Administer haloperidol decanoate (Haldol D) IM stat.
- D. Administer the PRN trihexyphenidyl (Artane) IM immediately.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) assessment, demonstrating acute extrapyramidal side effects (2) assessment, no validation required (3) Haldol is antipsychotic, will exacerbate symptoms (4) correct-administer Cogentin or Artane
The nurse is caring for a client with a history of gastroesophageal reflux disease (GERD).
- A. Which instruction is most appropriate for a client with GERD?
- B. Eat large meals to reduce acid production.
- C. Lie down immediately after eating.
- D. Elevate the head of the bed during sleep.
- E. Avoid drinking water with meals.
Correct Answer: C
Rationale: Elevating the head of the bed during sleep prevents acid reflux by using gravity to keep stomach contents down. Large meals and lying down post-meal worsen reflux, and water is neutral.
The nurse is caring for a client who is receiving a continuous IV infusion of dopamine for hypotension. Which of the following findings should the nurse report immediately?
- A. Heart rate of 100 bpm.
- B. Blood pressure of 90/60 mmHg.
- C. Urine output of 20 mL/hour.
- D. Respiratory rate of 18 breaths/min.
Correct Answer: C
Rationale: Urine output of 20 mL/hour indicates oliguria, suggesting inadequate perfusion despite dopamine. Options A, B, and D are expected.
Which of the following activities documented by the recreational therapist following a community reorientation outing for a paraplegic client would indicate to the nurse a readiness for discharge?
- A. The client states that he/she enjoyed being outside the hospital environment.
- B. The client was able to participate in a structured team sport by keeping score.
- C. The client was independently able to order his meal and feed himself.
- D. The client was independent in transfers and wheelchair mobility.
Correct Answer: D
Rationale: correct, physical, these skills are requisite for discharge
The nurse is assessing a client with a diagnosis of detached retina. Which of the following observations would support this diagnosis?
- A. Loss of acuity in the peripheral visual field.
- B. Increased lacrimation, blurred vision.
- C. Conjunctivitis, dilated pupils bilaterally.
- D. Photophobia, loss of a portion of the visual field.
Correct Answer: D
Rationale: bright flashes of light and client stating that portion of visual field is dark are classic symptoms