Nokea
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Administer pain medication at designated Intervals around the clock.
- B. Assess the pulses proximal to the fracture site.
- C. Remove traction every shift and provide skin care.
- D. Assess the pin sites for signs of infection.
Correct Answer: D
Rationale: Assessing pin sites for infection is critical in skeletal traction to prevent complications like osteomyelitis, which could delay healing.
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An adult client who was recently diagnosed with glaucoma tells the nurse, 'It feels like I am driving through a tunnel.' The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?
- A. Wear prescription glasses.
- B. Eat a diet high in carotene.
- C. Maintain prescribed eye drop regimen.
- D. Avoid frequent eye pressure measurements.
Correct Answer: C
Rationale: Adhering to eye drops controls intraocular pressure, critical for preventing vision loss in glaucoma.
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?
- A. Uneven hair distribution.
- B. Lower leg edema.
- C. Bronze pigmentation.
- D. Bounding peripheral pulse.
Correct Answer: A
Rationale: Uneven hair distribution results from reduced blood flow impairing hair follicle nutrition, a sign of peripheral arterial disease.
A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 mEq/L (120 mmol/L) to 125 mEq/L (125 mmol/L). Based on this finding, which intervention should the nurse implement?
- A. Withhold next scheduled dose of treatment.
- B. Maintain the prescribed fluid restriction.
- C. Assess for increasing fluid volume overload.
- D. Increase neurologic checks to every 2 hours.
Correct Answer: B
Rationale: Maintaining fluid restriction supports gradual correction of hyponatremia in SIADH, preventing further sodium dilution.
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Increase Intake of potassium rich foods such as bananas or cantaloupe.
- B. Restrict protein intake by limiting meats and other high protein foods.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of high fiber foods, such as bran cereal.
Correct Answer: B
Rationale: Restricting protein reduces kidney workload and proteinuria, preserving function in glomerulonephritis.
After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Increased temperature to lower extremity.
- B. Circumferential edema of right foot.
- C. Right foot pale with sluggish capillary refill.
- D. Reports throbbing right leg pain.
Correct Answer: C
Rationale: Pale foot with sluggish capillary refill indicates compromised circulation, risking tissue ischemia requiring urgent intervention.