Nokea
A client with a fractured femur is placed in skeletal traction. Which assessment finding requires immediate intervention?
- A. The client’s foot is cool to the touch.
- B. The client reports pain at the fracture site.
- C. The traction weights are resting on the floor.
- D. The client is performing active range of motion exercises.
Correct Answer: A
Rationale: A cool foot indicates potential vascular compromise, a serious complication in skeletal traction requiring immediate intervention to prevent tissue damage. Pain is expected, weights on the floor disrupt traction but are less urgent, and exercises are encouraged if appropriate.
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Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?
- A. Dysuria
- B. Epistaxis, hematuria, dysuria
- C. Vertigo, hematuria, ecchymosis
- D. Hematuria, ecchymosis, and epistaxis
Correct Answer: D
Rationale: Hematuria, ecchymosis, and epistaxis are the most common signs and symptoms of a heparin overdose, indicating bleeding tendencies.
A male client tells his nurse that he has had an ulcer in the past and is afraid it is 'flaring up again.' The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:
- A. Pain in the middle of the night
- B. A bowel movement every 3-5 days
- C. Melena
- D. Episodes of nausea and vomiting
Correct Answer: C
Rationale: Clients with ulcers generally experience abdominal pain. It is common to have pain in the early morning hours with an ulcer. Constipation is not a symptom associated with ulcers and would indicate a need to look at other factors. Melena is blood in the stools. This could indicate a slow bleeding ulcer, which could result in significant amounts of blood loss over time. Nausea and vomiting may be present as a result of the ulcer, especially if it is a gastric ulcer. This does not indicate an immediate life-threatening complication.
A client has developed diabetes insipidus after removal of a pituitary tumor. Which finding would the nurse expect?
- A. Polyuria
- B. Hypertension
- C. Polyphagia
- D. Hyperkalemia
Correct Answer: A
Rationale: Diabetes insipidus causes polyuria due to deficient antidiuretic hormone, leading to excessive water loss. Hypertension (B), polyphagia (C), and hyperkalemia (D) are not typical.
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
- A. Intake and output
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide is a nonpotassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity.
A client with a history of Cushing’s syndrome is admitted with complaints of weight gain. The nurse should expect the client to have:
- A. Moon face
- B. Weight loss
- C. Hypotension
- D. Bradycardia
Correct Answer: A
Rationale: Cushing’s syndrome causes excess cortisol, leading to moon face, central obesity, and weight gain.