Nokea
A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump?
Correct Answer: 30
Rationale: Concentration: 20,000 units ÷ 500 mL = 40 units/mL. Rate: 1200 units/hr ÷ 40 units/mL = 30 mL/hr.
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Which action by the nurse would be most appropriate for a child newly diagnosed with Reye's syndrome?
- A. Determining if the child had a bacterial infection recently
- B. Placing the child in a private room with droplet precautions
- C. Taking the child to the unit's play area to interact with others
- D. Assessing for signs of bleeding and for prolonged bleeding time
Correct Answer: D
Rationale: Assessing for bleeding is critical in Reye's syndrome due to liver dysfunction and potential coagulopathy.
While caring for multiple clients, the nurse delegates client skin care to the UAP on a musculoskeletal unit. Which client is most appropriate for the nurse to delegate skin care to the UAP?
- A. The client with osteomyelitis of the tibia who needs a wound dressing change
- B. The client with an inoperable hip fracture who is in Buck's traction
- C. The client with a pelvic fracture who is in skeletal traction
- D. The client with a femur fracture who has an external fixator in place
Correct Answer: B
Rationale: B. Buck's traction is skin traction. Because there is no open site that needs care with this type of traction, it would be appropriate to delegate skin care.
The client is a 73-year-old woman who fell in her home and suffered a right hip fracture. She tells the nurse that she was walking across the kitchen and felt something 'snap' in her hip and this made her fall. What type of fracture is the client most likely to have?
- A. Comminuted fracture
- B. Greenstick fracture
- C. Open fracture
- D. Pathological fracture
Correct Answer: D
Rationale: A 'snap' before falling suggests a pathological fracture, likely due to weakened bone (e.g., osteoporosis) in an elderly woman.
The occupational health nurse is teaching a class on the risk factors for developing osteoarthritis (OA). Which is a modifiable risk factor for developing OA?
- A. Being overweight.
- B. Increasing age.
- C. Previous joint damage.
- D. Genetic susceptibility.
Correct Answer: A
Rationale: Excess weight increases joint stress, a modifiable risk for OA. Age, prior damage, and genetics are nonmodifiable.
The nurse is assessing the client immediately following a C5-C6 anterior cervical discectomy. Which potential problem should be the nurse's priority?
- A. Altered breathing pattern
- B. Impaired tissue perfusion
- C. Altered mobility
- D. Impaired skin integrity
Correct Answer: A
Rationale: A. Retractors used during surgery can injure the recurrent laryngeal nerve, resulting in the inability to cough effectively to clear secretions. Edema and bleeding can also compromise the airway and compress the spinal cord.