Nokea
A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information should the nurse provide to the client to prevent complications?
- A. Trim the rough edges of the cast after it is dry.
- B. Weight bearing on the right leg is allowed once the cast feels dry.
- C. Expect burning and tingling sensations under the cast for 3 to 4 days.
- D. Keep the right ankle elevated above the heart level with pillows for 24 hours.
Correct Answer: D
Rationale: Leg elevation is important to increase venous return and decrease edema. Edema can cause compartment syndrome, a major complication of fractures and casting. The client and/or family may be taught how to 'petal' the cast to prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in skin integrity. Weight bearing on a fractured extremity is prescribed by the primary health care provider during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately.
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The nurse in an ambulatory care clinic takes a client's blood pressure (BP) in the left arm; it is 200/118 mm Hg. Which action should the nurse implement next?
- A. Notify the primary health care provider.
- B. Inquire about the presence of kidney disorders.
- C. Check the client's blood pressure in the right arm.
- D. Recheck the pressure in the same arm within 30 seconds.
Correct Answer: C
Rationale: When a high BP reading is noted, the nurse takes the pressure in the opposite arm to see if the blood pressure is elevated in one extremity only. The nurse would also recheck the blood pressure in the same arm but would wait at least 2 minutes between readings. The nurse would inquire about the presence of kidney disorders that could contribute to the elevated blood pressure. The nurse would notify the primary health care provider because immediate treatment may be required, but this would not be done without obtaining verification of the elevation.
The nurse analyzed an electrocardiogram (ECG) strip (refer to figure) for a client demonstrating left-sided heart failure and interprets the ECG strip as which rhythm?
- A. Atrial fibrillation
- B. Sinus dysrhythmia
- C. Ventricular fibrillation
- D. Third-degree heart block
Correct Answer: A
Rationale: Atrial fibrillation is characterized by rapid, chaotic atrial depolarization. Ventricular rates may be less than 100 beats per minute (controlled) or greater than 100 beats per minute (uncontrolled). The ECG reveals chaotic or no identifiable P waves and an irregular ventricular rhythm. A sinus dysrhythmia has a normal P wave and PR interval and QRS complex. In ventricular fibrillation, there are no identifiable P waves, QRS complexes, or T waves.
The nurse monitoring a preterm newborn infant for manifestations of respiratory distress syndrome (RDS) should assess the infant for which manifestations? Select all that apply.
- A. Cyanosis
- B. Tachypnea
- C. Retractions
- D. Nasal flaring
- E. Acrocyanosis
- F. Grunting respirations
Correct Answer: A,B,C,D,F
Rationale: The newborn infant with RDS may present with clinical manifestation of cyanosis, tachypnea or apnea, chest wall retractions, audible grunts, or nasal flaring. Acrocyanosis, the bluish discoloration of the hands and feet, is associated with immature peripheral circulation and is not uncommon in the first few hours of life.
The nurse caring for a 5-year-old with a history of tetralogy of Fallot notes that the child has clubbed fingers. This finding is indicative of which associated condition?
- A. Tissue hypoxia
- B. Chronic hypertension
- C. Delayed physical growth
- D. Destruction of bone marrow
Correct Answer: A
Rationale: Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of chronic tissue hypoxia and polycythemia. Options 2, 3, and 4 do not cause clubbing.
A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis?
- A. Slowed reflexes
- B. Continuous drooling
- C. Diaphragmatic breathing
- D. Passage of large amounts of frothy stool
Correct Answer: B
Rationale: In esophageal atresia, the esophagus terminates before it reaches the stomach, ending in a blind pouch. This condition prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth and the infant then drools continuously. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of esophageal atresia. Diaphragmatic breathing is not associated with this disorder. The inability to swallow amniotic fluid in utero prevents the accumulation of normal meconium, and lack of stools results.