Nokea
A client with a fractured femur has been in Russell's traction for 24 hours. Which nursing action is associated with this therapy?
- A. Check the skin on the sacrum for breakdown
- B. Inspect the pin site for signs of infection
- C. Auscultate the lungs for atelectasis
- D. Perform a neurovascular check for circulation
Correct Answer: D
Rationale: Perform a neurovascular check for circulation. While each of these is an important assessment, the neurovascular integrity check is most associated with this type of traction. Russell's traction is Buck's traction with a sling under the knee.
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The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?
- A. Confront the nurse about the suspicions in a private meeting
- B. Schedule a staff conference, without the nurse present, to collect information
- C. Consult the human resources department about the issue and needed actions
- D. Counsel the employee to resign to avoid investigation
Correct Answer: C
Rationale: Consult the human resources department about the issue and needed actions. To avoid legal repercussions, the nurse needs to consult with the human resources department for proper procedure for documentation, counseling and available resources.
Which of the following meal choices is suitable for a 6-month-old infant?
- A. Egg white, formula, and orange juice
- B. Apple juice, carrots, and whole milk
- C. Rice cereal, formula, and apple juice
- D. Melba toast, egg yolk, and whole milk
Correct Answer: C
Rationale: Rice cereal, formula, and apple juice are appropriate for a 6-month-old, as they are easily digestible and safe. Egg whites, whole milk, and orange juice are not recommended before 1 year due to allergy and digestive risks.
The nurse is to suction a client. What action is essential prior to inserting the suction catheter?
- A. Clear the mouth and throat of secretions.
- B. Lower the head of the bed.
- C. Oxygenate the client.
- D. Check the suction pressure.
Correct Answer: C
Rationale: Pre-oxygenation prevents hypoxia during suctioning, a critical step. Clearing secretions, lowering the bed, or checking pressure are secondary.
After abdominal surgery, a client has a nasogastric tube attached to low suctioning.
- A. What is the most appropriate nursing intervention for a client with a nasogastric tube who becomes nauseated with decreased gastric secretion flow?
- B. Irrigate the nasogastric tube with distilled water.
- C. Aspirate the gastric contents with a syringe.
- D. Administer an antiemetic medicine.
- E. Insert a new nasogastric tube.
Correct Answer: B
Rationale: Nausea and decreased flow suggest possible NG tube obstruction. Aspirating gastric contents with a syringe confirms tube placement (pH 0-4) and checks for blockages, addressing the cause of symptoms. Irrigation should use normal saline after placement confirmation, and antiemetics or tube replacement do not assess tube function.
The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Heart rate of 90 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.