Nokea
A client with a compound (open) fracture of the radius has a plaster cast applied in the emergency department. The nurse provides home care instructions and tells the client to seek medical attention if which finding occurs?
- A. Numbness and tingling are felt in the fingers.
- B. The cast feels heavy and damp after 24 hours of application.
- C. The entire cast feels warm during the first 24 hours after application.
- D. Slightly bloody drainage is noted on the cast during the first 6 hours after application.
Correct Answer: A
Rationale: A limb encased in a cast is at risk for nerve damage and diminished circulation from increased pressure caused by edema. Signs/symptoms of increased pressure from the cast include numbness, tingling, and increased pain. A cast can take up to 48 hours to dry and generates heat while drying. Some drainage may occur initially with a compound (open) fracture.
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The nurse is teaching a new mother about postpartum fatigue (PPF). Which information would the nurse include?
- A. PPF is more common in women with cesarean births.
- B. Fatigue usually improves over the first 6 weeks after birth.
- C. Fatigue can help reduce the incidence of postpartum depression.
- D. Nursing mothers can minimize fatigue by breastfeeding in the side-lying position.
Correct Answer: B,D
Rationale: Fatigue improves over 6 weeks, and side-lying breastfeeding conserves energy. Cesarean births don't inherently increase PPF, and fatigue may worsen depression.
The nurse has completed discharge teaching with a client who has had surgery for lung cancer. The nurse determines that the client needs additional teaching about the elements of home management if the client verbalizes the need to follow which instruction?
- A. Avoid exposure to crowds.
- B. Deal with any increases in pain independently.
- C. Sit up and lean forward to breathe more easily.
- D. Call the primary health care provider if shortness of breath occurs.
Correct Answer: B
Rationale: Clients post-lung cancer surgery should not manage increased pain independently, as it may indicate complications requiring medical attention. Avoiding crowds, sitting up to breathe easier, and reporting shortness of breath are appropriate home management strategies.
The nurse prepares a client with a peripheral intravenous (IV) site for home IV therapy for discharge. Which should the nurse teach the client to help prevent phlebitis and infiltration?
- A. Massage the IV site daily.
- B. Immobilize the extremity.
- C. Stabilize the cannula with tape.
- D. Cleanse the site daily with alcohol.
Correct Answer: C
Rationale: Stabilizing the cannula with tape prevents movement, reducing the risk of phlebitis and infiltration. Massaging the site can cause tissue damage, immobilizing the extremity is unnecessary, and alcohol cleansing causes skin drying and discomfort.
The nurse is conducting a health screening on a client with a family history of hypertension. Which assessment finding should alert the nurse to the need for further teaching related to stroke (brain attack) prevention?
- A. Eats two bowls of high-fiber grain cereal with skim milk for breakfast
- B. Has a blood pressure of 118/78 mm Hg and has lost 10 pounds recently
- C. Uses condoms for pregnancy and disease prevention and jogs 2 miles daily
- D. Uses oral contraceptives for pregnancy prevention and works as a manager of a busy medical-surgical unit
Correct Answer: D
Rationale: Oral contraceptives increase clot formation risk, a modifiable stroke risk factor, especially with a hypertension family history. High-fiber diet, normal blood pressure, weight loss, and exercise (options A, B, C) reduce stroke risk.
The nurse has provided home-care instructions to a client who is taking lithium carbonate. Which client statement indicates that the client understands the prescribed regimen?
- A. I will restrict my water intake.
- B. I will make sure that my diet contains salt.
- C. I will keep my medication in the refrigerator.
- D. I will be careful to avoid eating foods high in potassium.
Correct Answer: B
Rationale: Lithium is a mood stabilizer used to treat bipolar disorder. It replaces sodium ions in the cells and induces the excretion of sodium and potassium from the body. Client teaching includes the maintenance of sodium intake in the daily diet and increased fluid intake (at least 1 to 1½ L per day) during maintenance therapy. Lithium is stored at room temperature and protected from light and moisture.