Nokea
A client with a fractured femur is placed in skeletal traction. The nurse should assess the client for which of the following complications?
- A. Pressure ulcers.
- B. Deep vein thrombosis.
- C. Hypovolemia.
- D. Infection at the pin sites.
Correct Answer: B,D
Rationale: Skeletal traction increases the risk of deep vein thrombosis due to immobility and infection at pin sites due to skin penetration.
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The nurse is assessing a client with a suspected diverticulitis. Which of the following findings is most indicative of this condition?
- A. Left lower quadrant pain.
- B. Right upper quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Left lower quadrant pain is a hallmark sign of diverticulitis due to inflammation of diverticula in the sigmoid colon.
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
- A. Stop the intravenous flow
- B. Slow down the intravenous flow
- C. Notify the doctor
- D. Begin CPR
Correct Answer: A
Rationale: Stopping the IV flow immediately halts the administration of the allergen, which is the priority in anaphylaxis.
A client has been diagnosed with viral hepatitis. Which of the following goals is most appropriate for the client?
- A. Achieve control of abdominal pains
- B. Increase activity levels gradually
- C. Reduce jaundice
- D. Prevent liver damage
Correct Answer: B
Rationale: Increasing activity levels gradually is an appropriate goal for viral hepatitis, as rest is needed initially but gradual return to activity supports recovery. Pain is less common, and jaundice or liver damage prevention are secondary.
A client is receiving spironolactone (Aldactone) for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which of the following nutritional modifications to prevent an electrolyte imbalance?
- A. Increase intake of milk and milk products.
- B. Restrict fluid intake to 1000 mL per day.
- C. Decrease foods high in potassium.
- D. Decrease foods high in sodium.
Correct Answer: C
Rationale: Spironolactone is a potassium-sparing diuretic, so decreasing potassium-rich foods prevents hyperkalemia. Sodium restriction may help edema but is less critical for electrolyte balance in this context.
A client who has Ménière's disease is trying to cope with the chronic tinnitus that she is experiencing. Which of the following interventions is most appropriate for the nurse to suggest for coping with the tinnitus?
- A. Maintain a quiet environment.
- B. Play background music.
- C. Avoid caffeine and nicotine.
- D. Take a mild sedative.
Correct Answer: B
Rationale: Background music can mask tinnitus, helping the client cope by reducing the perception of the noise.