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A client who has undergone internal fixation after fracturing a left hip has developed a reddened left heel. What equipment should the nurse obtain to manage this problem?
- A. Trapeze
- B. Bed cradle
- C. Draw sheet
- D. Alternating pressure mattress
Correct Answer: D
Rationale: The reddened heel results from the pressure of the foot against the mattress. An alternating pressure mattress is effective at minimizing pressure points. The bed cradle will keep the linens off of the client's lower extremities but will not assist with the management of a reddened heel. A draw sheet and trapeze are of general use for this client, but they are not specific for dealing with the reddened heel.
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A client with a history of hypertension has been prescribed triamterene. The nurse provides information to the client about the medication and instructs the client to avoid consuming which fruit?
- A. Pears
- B. Apples
- C. Bananas
- D. Cranberries
Correct Answer: C
Rationale: Triamterene is a potassium-retaining diuretic, and the client should avoid foods that are high in potassium. Fruits that are naturally higher in potassium include avocados, bananas, oranges, mangoes, cantaloupe, strawberries, nectarines, papayas, and dried prunes.
A client in the second trimester of pregnancy is being assessed at the primary health care clinic. The nurse notes that the fetal heart rate (FHR) is 100 beats/min. Which nursing action would be appropriate initially?
- A. Document the findings as normal.
- B. Notify the primary health care provider of the finding.
- C. Inform the mother that the assessment is normal and everything is fine.
- D. Instruct the mother to return to the clinic in 8 hours for reevaluation of the FHR.
Correct Answer: B
Rationale: The FHR should be between 120 and 160 beats/min during pregnancy. An FHR of 100 beats/min would require that the primary health care provider be notified and the client be further evaluated. Although the nurse would document the findings, the most appropriate nursing action is to notify the primary health care provider. Based on this information, eliminate the options that suggest inaccurate nursing actions.
The nurse is planning care for an infant with a diagnosis of an encephalocele located in the occipital area. Which item should the nurse use to assist with positioning the child to avoid pressure on the encephalocele?
- A. Sandbags
- B. Sheepskin
- C. Feather pillows
- D. Foam half donut
Correct Answer: D
Rationale: The infant is positioned to avoid pressure on the lesion. If the encephalocele is in the occipital area, a foam half donut may be useful for positioning to prevent this pressure. A sandbag, sheepskin, or feather pillow will not protect the encephalocele from pressure.
The nurse is asked to assist another health care team member with providing care for a client. On entering the client's room, the nurse notes that the client is placed in this position (refer to figure). After maintaining the client position, what should the nurse interpret that this client is most likely being treated for?
- A. Shock
- B. A head injury
- C. Respiratory insufficiency
- D. Increased intracranial pressure
Correct Answer: A
Rationale: A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat, and elevating the head and shoulders slightly. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm. The Trendelenburg position is no longer recommended for hypotensive clients because the client is predisposed to aspiration and worsens gas exchange. The remaining options identify conditions in which the head of the client's bed would be elevated.
A client in the late, active, first stage of labor has just reported a gush of vaginal fluid. The nurse observes a fetal monitor pattern of variable decelerations during contractions followed by a brief acceleration. After that, there is a return to baseline until the next contraction, when the pattern is repeated. On the basis of these data, what is the nurse's initial intervention?
- A. Take the client's vital signs.
- B. Perform a Leopold's maneuver.
- C. Perform a manual sterile vaginal exam.
- D. Test the vaginal fluid with a Nitrazine strip.
Correct Answer: C
Rationale: Variable deceleration with brief acceleration after a gush of amniotic fluid is a common clinical manifestation of cord compression caused by occult or frank prolapse of the umbilical cord. A manual vaginal exam can detect the presence of the cord in the vagina, which confirms the problem. On the basis of the data in the question, none of the remaining options are initial actions.