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A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply)
- A. Verify pedal pulses using a doppler pulse device.
- B. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
- C. Evaluate the application of the splint to the left leg.
Correct Answer: C
Rationale: It is crucial for the nurse to evaluate the application of the splint to the left leg in a client with diminished distal pulses. This assessment helps ensure that the splint is not causing any compromise to circulation. Verifying pulses and monitoring for leg conditions are important interventions but do not directly address the issue with the splint application in this scenario, making them less relevant.
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A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
- A. Report when hematuria becomes pink-tinged
- B. Use incentive spirometer
- C. Restrict physical activities
- D. Monitor urinary stream for a decrease in output
Correct Answer: D
Rationale: After lithotripsy, monitoring the urinary stream for a decrease in output is essential to identify any potential complications such as urinary retention or obstruction. Reporting pink-tinged hematuria is important, but monitoring the urinary stream for a decrease in output takes precedence as it directly assesses renal function and potential complications. Using an incentive spirometer is not directly related to post-lithotripsy care. Restricting physical activities may be necessary initially but is not the priority compared to monitoring urinary output.
A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
- A. Osmolarity
- B. Glucose
- C. Albumin
- D. Platelets
Correct Answer: B
Rationale: The correct answer is B: Glucose. Hydrocortisone can lead to increased blood glucose levels, so monitoring glucose is crucial to assess for hyperglycemia, a common side effect of corticosteroid therapy. Monitoring osmolarity (choice A) is not typically indicated in this scenario. Albumin (choice C) and platelets (choice D) are not directly affected by hydrocortisone therapy and are not the primary focus of monitoring in this case.
Before selecting which medication to administer, which action should the nurse implement if a postoperative client reports incisional pain and has two prescriptions for PRN analgesia?
- A. Compare the client's pain scale rating with the prescribed dosing.
- B. Determine which prescription will have the quickest onset of action.
- C. Ask the client to choose which medication is needed for the pain.
- D. Document the client's report of pain in the electronic medical record.
Correct Answer: A
Rationale: When a postoperative client reports incisional pain and has two prescriptions for PRN analgesia, the nurse should first compare the client's pain scale rating with the prescribed dosing. This action ensures that the client receives the appropriate medication based on their pain level. Determining the onset of action or asking the client to choose the medication does not guarantee that the right medication is administered according to the pain intensity. Documenting the pain report is important but should not be the first action when deciding which medication to administer.
The cognitive impairment is classified into four levels based on the intelligence quotient (IQ). How is a child with an IQ of 45 classified?
- A. Within the normal low range
- B. Educable
- C. Trainable
- D. Severe
Correct Answer: C
Rationale: A child with an IQ of 45 is classified as 'Trainable' in the context of cognitive impairment levels. This category is determined by an IQ range of 35 to 55. Choice A ('Within the normal low range') is incorrect as an IQ of 45 falls within the range associated with the 'Trainable' level, not the 'Normal low range.' Choice B ('Educable') is incorrect because this classification typically corresponds to individuals with slightly higher IQs that allow for academic progress with support. Choice D ('Severe') is incorrect as it does not align with the IQ level of 45, which falls within the 'Trainable' category.
What assessment findings should lead the nurse to suspect Down syndrome in a newborn?
- A. Hypertonia and dark skin
- B. Low-set ears and a simian crease
- C. Inner epicanthal folds and a high, domed forehead
- D. Long, thin fingers and excessive hair
Correct Answer: B
Rationale: The correct answer is B: 'Low-set ears and a simian crease.' These are key physical characteristics commonly seen in newborns with Down syndrome. Low-set ears, along with a simian crease (a single palmar crease), are indicative of Down syndrome. Choices A, C, and D are incorrect because hypertonia, dark skin, inner epicanthal folds, a high, domed forehead, long, thin fingers, and excessive hair are not specific features associated with Down syndrome in newborns. Therefore, the presence of low-set ears and a simian crease should raise suspicion for Down syndrome and prompt further evaluation.