Nokea
A client with a total knee replacement returns from surgery. Which finding requires immediate nursing intervention?
- A. There is $30 \mathrm{~mL}$ of bloody drainage from the Davol drain.
- B. The continuous passive motion machine is set on $90^{\circ}$ flexion.
- C. The client is unable to ambulate to the bathroom.
- D. The client is complaining of muscle spasms.
Correct Answer: B
Rationale: A 90° flexion setting on the CPM machine is too aggressive post-surgery, risking injury, and requires immediate adjustment. Drainage , non-ambulation , and spasms are expected or less urgent.
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A client with an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L has digoxin (Lanoxin) ordered.
Which of the following actions if taken by the nurse is BEST?
- A. Give the digoxin.
- B. Hold the digoxin.
- C. Notify the physician.
- D. Re-check the pulse.
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) although the pulse is normal, level of potassium must be considered (2) notify physician about low potassium (3) correct-hypokalemia can precipitate digoxin toxicity; physician should be called to obtain order for potassium supplement (4) notify physician about the potassium level
The nurse is caring for a six-year-old boy several hours after the application of a hip spica cast.
- A. What should the nurse do first for a six-year-old complaining of pain in his left foot several hours after hip spica cast application?
- B. Elevate the left leg on two pillows.
- C. Palpate the cast for warmth and wetness.
- D. Administer pain medication as ordered.
- E. Check the blanching sign on both feet.
Correct Answer: D
Rationale: Pain in the foot post-cast application suggests possible circulatory impairment. Checking the blanching sign (capillary refill) assesses circulation, comparing the affected and unaffected sides. Elevation, palpation, or medication may follow but do not address the urgent need to assess circulation.
Which laboratory test conducted on the client with diabetes mellitus indicates compliance?
- A. Fasting blood glucose
- B. Two-hour post-prandial
- C. Hgb A-1C
- D. Dextrostix
Correct Answer: C
Rationale: Hgb A-1C reflects average blood glucose over 2-3 months, indicating long-term compliance. Options A, B, and D provide short-term snapshots and are less reliable for compliance.
A six-year-old boy with a history of epilepsy admitted with uncontrolled seizures.
It is MOST important for the nurse to ask which of the following questions?
- A. What part of the body was affected by the seizure?'
- B. What is the family history of seizure disorders?'
- C. What was your son doing before the seizure?'
- D. How long has it been since his last episode of seizures?'
Correct Answer: C
Rationale: Strategy: 'MOST important' indicates that this is a priority question. (1) not most important question (2) should be included in detailed history, but will not prevent an immediate reoccurrence (3) correct-seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged reading, drugs) (4) should be included in detailed history, but will not prevent an immediate reoccurrence
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Weight gain of 5 pounds in a month.
- C. Occasional joint stiffness.
- D. Mild headache.
Correct Answer: B
Rationale: Weight gain of 5 pounds in a month suggests prednisone-induced fluid retention, requiring evaluation. Options A, C, and D are less urgent.