Nokea
A client is admitted with suspected fracture of the left hip. The most consistent finding in the client with the hip fracture is:
- A. Pain in the hip and affected leg
- B. Absence of pedal pulses
- C. Disalignment of the leg
- D. Diminished sensation
Correct Answer: C
Rationale: Disalignment of the leg , such as shortening or external rotation, is the most consistent sign of a hip fracture. Pain is common but less specific. Pulses and sensation are typically intact.
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A client on assisted ventilation develops a right-sided tension pneumothorax. Which of the following signs is associated with a right-sided tension pneumothorax?
- A. Diminished breath sounds on the right
- B. Left-sided tracheal deviation
- C. Right-sided tracheal deviation
- D. Presence of bilateral ronchi
Correct Answer: A
Rationale: Tension pneumothorax causes lung collapse, reducing breath sounds on the affected side (right). Tracheal deviation is toward the unaffected side (left).
A diabetic client has been maintained on Glucophage (metformin) for regulation of his blood glucose levels. Which teaching should be included in the plan of care?
- A. Report changes in urinary pattern.
- B. Allow six weeks for optimal effects.
- C. Increase the amount of carbohydrates in your diet.
- D. Use lotions to treat itching.
Correct Answer: A
Rationale: Metformin can affect kidney function, so changes in urinary patterns should be reported. Optimal effects occur sooner than six weeks , carbohydrates should be balanced, not increased , and itching is not a common side effect .
The nurse is caring for a client with a history of irritable bowel syndrome.
- A. Which dietary instruction is most appropriate for a client with irritable bowel syndrome?
- B. Avoid caffeine and alcohol.
- C. Eat large, infrequent meals.
- D. Consume a high-fat diet.
- E. Limit fiber intake.
Correct Answer: A
Rationale: Avoiding caffeine and alcohol reduces gut irritation in irritable bowel syndrome. Small, frequent meals, balanced fiber, and low-fat diets are recommended.
The nurse is caring for a patient admitted two days ago with a diagnosis of closed head injury. If the patient develops diabetes insipidus, the nurse would observe which of the following symptoms?
- A. Decerebrate posturing, BP 160/100, pulse 56.
- B. Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004.
- C. Glucosuria, osmotic diuresis, loss of water and electrolytes.
- D. Weight gain of 5 lb, pulse 116, serum sodium 110 mEq/L.
Correct Answer: B
Rationale: signs of dehydration, increased output, low specific gravity, normal 1.010-1.030
During a first aid class, the nurse instructs clients on the emergency care of second-degree burns.
- A. Which intervention for second-degree burns of the chest and arms best prevents infection?
- B. Wash the burn with an antiseptic soap and water.
- C. Remove clothing and wrap the victim in a clean sheet.
- D. Leave the blisters intact and apply an ointment.
- E. Take no action until the victim arrives in a burn unit.
Correct Answer: B
Rationale: Removing clothing and wrapping the victim in a clean sheet minimizes contamination and prevents infection in an emergency setting. Soap, ointments, or delaying action increase infection risk by introducing irritants or leaving the wound exposed.