Nokea
A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure?
- A. A condition.
- B. Jaundice.
- C. Generalized edema.
- D. Dark, scanty urine.
Correct Answer: D
Rationale: Dark, scanty urine indicates renal failure, a potential complication of compartment syndrome due to myoglobin release.
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The primary healthcare provider (PHCP) prescribes medication via the buccal route. To correctly administer this medication, the nurse plans to place the medication
- A. in the client's ear while holding the pinna down and back.
- B. under the client's tongue.
- C. in the client's mouth toward the cheek.
- D. into the client's nasal passage.
Correct Answer: C
Rationale: Buccal administration involves placing the medication in the cheek pouch for absorption through the oral mucosa.
A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should first-aid for this victim should be selected that apply.
- A. Establish an airway with the jaw-thrust maneuver.
- B. Immobilize the spine.
- C. Logroll the victim to a side-lying position.
- D. Elevate the feet 6" (15.2 cm).
- E. Place a cervical collar around the neck.
Correct Answer: A,B,E
Rationale: For a suspected cervical spine injury, the airway should be opened with the jaw-thrust maneuver, the spine immobilized, and a cervical collar applied to prevent further injury. Logrolling or elevating feet could exacerbate the injury.
What should the nurse assess in a client receiving anticonvulsant therapy?
- A. Liver function.
- B. Blood pressure.
- C. Pain levels.
- D. Skin integrity.
Correct Answer: A
Rationale: Liver function is assessed due to the potential hepatotoxicity of anticonvulsant medications.
The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month five clients were diagnosed with pressure ulcers. The nurse manager should:
- A. Use benchmarking procedures to compare the findings with other nursing units in the hospital.
- B. Ask the staff education department to conduct an educational session about preventing pressure ulcers.
- C. Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes.
- D. Conduct a chart audit to determine which nurses on which shifts were giving nursing care to the clients with pressure ulcers.
Correct Answer: C
Rationale: A quality improvement plan addresses root causes, proposes solutions, and sets measurable outcomes, effectively reducing pressure ulcer incidence.
Prior to being transported to the surgery suite, the nurse asks the client whether he has any allergies. The client responds, 'Doesn't anyone communicate with anyone? I have been asked that question over and over!' What is the nurse's best response?
- A. œI'm sorry! I just have to ask that question for the record.'
- B. œIt's an important question and we just have to check.'
- C. œYou will hear it again and again as you go through surgery.'
- D. œThis question is asked for verification and safety with each new phase of treatment.'
Correct Answer: D
Rationale: Explaining that repeated allergy checks are for safety and verification reassures the client while clarifying the purpose of the question. This response addresses the client's frustration and emphasizes the importance of the process.