Nokea
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
- A. Call the health care provider
- B. Access the use of a window in the cast
- C. Simply record the findings in the nurse's notes only
- D. Outline the spot with a pencil and note the time and date on the cast
Correct Answer: D
Rationale: Outline the spot with a pencil and note the time and date on the cast. This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse's notes.
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The nurse believes a coworker is diverting narcotics. The nurse approaches the nurse manager to report the suspicions. Which of the following statements by the nurse is BEST?
- A. After my coworker has been on duty, the patients often need repeated doses of pain medication. I have seen her/him sleeping on duty three times.
- B. I saw my coworker downtown after work. S/he was acting really strange, like s/he didn't even recognize me.
- C. I think my coworker is stealing narcotics because s/he is always acting euphoric and seems high.
- D. I am sure my coworker is hanging around with drug dealers, and I think I saw tracks on her/his arms.
Correct Answer: A
Rationale: Objective observations, such as increased patient pain medication needs and sleeping on duty, provide verifiable evidence for investigation. Options B, C, and D are subjective or speculative, reducing their credibility.
A man is presently employed as a night watchman. When he comes to the clinic for a visit, he tells the nurse he is having difficulty sleeping and is fatigued much of the time.
Which of the following responses by the nurse is BEST?
- A. Tell me about your usual sleeping habits.'
- B. You probably sleep when you can during your night tour.'
- C. This is normal for your age group.'
- D. Working the night shift is known to disrupt sleep patterns.'
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assessment, open-ended, encourages discussion (2) judgment based on inadequate information, nontherapeutic (3) generalization with no factual basis, closed communication (4) closed communication, generalization
A client is readmitted with a recurrent urinary tract infection. The client is to be discharged home on methenamine mandelate (Mandelamine). The nurse should instruct the client to limit intake of which of the following fluids?
- A. Milk.
- B. Juices.
- C. Water.
- D. Tea.
Correct Answer: A
Rationale: should limit intake of alkaline foods and fluids, such as milk
A nurse is assessing a patient that has undergone a recent CABG. The nurse notices a mole with irregular edges with a bluish color. The nurse should:
- A. Recommend a dermatological consult to the MD.
- B. Note the location of the mole and contact the physician via the telephone.
- C. Note the location of the mole and follow-up with the attending physician via the medical record and phone call.
- D. Remove the mole with a sharp's debridement technique, following charge nurse approval.
Correct Answer: C
Rationale: Contacting the attending physician via the medical record is appropriate due to the possibility of melanoma.
The infant of a diabetic mother has a blood glucose of 90 mg/dL and a serum calcium level of 7.0 mg/dL. The nurse should anticipate that which of the following medications would be administered IV?
- A. Insulin.
- B. Glucose.
- C. Phenobarbital.
- D. Calcium gluconate.
Correct Answer: D
Rationale: Hypocalcemia (7.0 mg/dL) in infants of diabetic mothers risks tetany; calcium gluconate is indicated. Options A, B, and C are inappropriate.