Nokea
A client wearing an arm cast reports numb fingers. Which of the following actions should the nurse take first?
- A. Place the arm in a dependent position
- B. Administer pain medication
- C. Check the client's circulation
- D. Apply a warm compress to the fingers
Correct Answer: C
Rationale: The correct answer is to check the client's circulation. Numbness in the fingers may indicate compromised circulation or nerve damage. By assessing the circulation first, the nurse can ensure that the cast is not too tight, which could be cutting off blood flow. Option A is incorrect because placing the arm in a dependent position may worsen circulation issues. Option B is incorrect as administering pain medication does not address the underlying cause of numbness. Option D is incorrect as applying a warm compress could mask circulation issues and is not the priority in this situation.
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A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?
- A. Holding the newborn in an en face position
- B. Asking the father to change the newborn's diaper
- C. Requesting the nurse to take the newborn to the nursery so she can rest
- D. Viewing the newborn's actions as uncooperative
Correct Answer: D
Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a negative interaction with the newborn and suggests impaired bonding, which requires intervention. Choices A, B, and C are not indicative of impaired bonding. Holding the newborn in an en face position is a positive way to bond with the baby. Asking the father to change the diaper shows involvement of both parents in caring for the newborn, which is beneficial for bonding. Requesting the nurse to take the newborn to the nursery so the mother can rest is a normal request and does not necessarily indicate impaired bonding.
A client is recovering from an acute myocardial infarction. Which of the following interventions should the nurse include in the plan of care?
- A. Draw a troponin level every four hours
- B. Perform an EKG every 12 hours
- C. Plan for oxygen therapy with a rebreather mask
- D. Obtain a cardiac rehabilitation consult
Correct Answer: D
Rationale: The correct answer is to obtain a cardiac rehabilitation consult. Cardiac rehabilitation is an essential part of the care plan for a client recovering from a myocardial infarction. It helps in improving recovery, enhancing quality of life, and reducing the risk of future cardiac events. Drawing troponin levels and performing EKGs are important for diagnosing and monitoring myocardial infarctions but are not interventions in the post-MI care plan. Oxygen therapy may be necessary based on the client's condition but is not specific to post-MI care.
A charge nurse is discussing the use of applying ice to a client's injured knee with a newly licensed nurse. Which of the following is a benefit of this treatment?
- A. Systemic analgesic effect
- B. Increase in metabolism
- C. Decreased capillary permeability
- D. Vasodilation
Correct Answer: C
Rationale: The correct answer is C: Decreased capillary permeability. Ice application helps decrease capillary permeability, which in turn reduces swelling and inflammation at the injury site. This vasoconstriction effect helps to limit the extent of the injury. Choices A, B, and D are incorrect. Applying ice locally does not produce a systemic analgesic effect but rather a localized numbing effect. It does not increase metabolism but rather slows down metabolic processes in the affected area. Additionally, ice application causes vasoconstriction, not vasodilation.
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?
- A. Place the infant under a radiant warmer
- B. Move the probe site every 3 hours
- C. Heat the skin one minute prior to placing the probe
- D. Place the sensor on the index finger
Correct Answer: B
Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures more accurate monitoring of oxygen saturation. Placing the infant under a radiant warmer (choice A) is unnecessary and not related to pulse oximetry. Heating the skin before placing the probe (choice C) can lead to burns and is not recommended. Placing the sensor on the index finger (choice D) is not appropriate for continuous monitoring in infants.
A nurse is assessing a client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find?
- A. Meat and dairy products are eaten together
- B. Fasting occurs during Hanukkah
- C. Shellfish is eaten regularly
- D. Meat and dairy products are consumed separately
Correct Answer: D
Rationale: The correct answer is D: 'Meat and dairy products are consumed separately.' Kosher dietary laws prohibit the consumption of meat and dairy products together. Observing this separation is a key aspect of Jewish dietary practices. Choice A is incorrect as meat and dairy products are not eaten together in kosher dietary practices. Choice B is incorrect as fasting does not typically occur during Hanukkah. Choice C is incorrect as shellfish is not eaten in kosher dietary practices due to being non-kosher.