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A healthcare provider is caring for a client who has a leg fracture and reports severe pain. Which of the following actions should the healthcare provider take first?
- A. Administer pain medication
- B. Reposition the client's leg
- C. Elevate the client's leg
- D. Check the client's neurovascular status
Correct Answer: D
Rationale: Checking the client's neurovascular status is the priority when caring for a client with severe pain after a leg fracture. This assessment is crucial to identify any signs of vascular compromise or nerve damage, such as compartment syndrome. Administering pain medication can help alleviate the pain but should only be done after ensuring the client's neurovascular status is stable. Repositioning or elevating the leg may worsen the condition if there are underlying vascular issues, making these options lower in priority than assessing neurovascular status.
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How should a healthcare provider educate a patient with hypertension about lifestyle modifications?
- A. Reduce sodium intake
- B. Increase physical activity
- C. Quit smoking
- D. Avoid alcohol
Correct Answer: A
Rationale: When educating a patient with hypertension about lifestyle modifications, reducing sodium intake is crucial as excess sodium can contribute to high blood pressure. While increasing physical activity is beneficial for overall health, it is not the primary lifestyle modification specifically targeted at hypertension. Quitting smoking and avoiding alcohol are important for general health but are not the first-line lifestyle modifications recommended for hypertension. Therefore, the correct answer is to reduce sodium intake.
Which of the following is an early sign that suctioning is required for a client with a tracheostomy?
- A. Bradycardia
- B. Irritability
- C. Confusion
- D. Hypotension
Correct Answer: B
Rationale: Irritability is an early sign that suctioning is necessary to clear the airway in a client with a tracheostomy. When secretions build up in the tracheostomy tube, the client may become irritable due to the discomfort and the compromised airway. Bradycardia, confusion, and hypotension are not typically early signs that suctioning is required. Bradycardia may occur if the airway becomes severely compromised, confusion may be a late sign of hypoxia, and hypotension is not directly related to the need for suctioning in a client with a tracheostomy.
A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin A1c of 6%
- B. Fasting blood glucose of 90 mg/dL
- C. Blood glucose of 200 mg/dL
- D. Blood glucose of 100 mg/dL
Correct Answer: C
Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.
What are the signs and symptoms of fluid overload?
- A. Edema, shortness of breath, weight gain
- B. High blood pressure and jugular venous distention
- C. Low blood pressure and cyanosis
- D. Tachycardia and dizziness
Correct Answer: A
Rationale: The correct signs and symptoms of fluid overload include edema, shortness of breath, and weight gain. Edema is the abnormal accumulation of fluid causing swelling, shortness of breath can occur due to fluid accumulating in the lungs, and weight gain is often seen as a result of excess fluid retention. Choices B, C, and D are incorrect because high blood pressure and jugular venous distention are more indicative of conditions like heart failure, while low blood pressure and cyanosis are seen in conditions like shock or poor perfusion. Tachycardia and dizziness are not typical signs of fluid overload.
A nurse is caring for a client with a chest tube post-surgery. What is the most important assessment?
- A. Ensure the chest tube is clamped periodically
- B. Check for air leaks and ensure proper chest tube function
- C. Encourage deep breathing and coughing every 2 hours
- D. Ensure the client is positioned in a high Fowler's position
Correct Answer: B
Rationale: The correct answer is B: 'Check for air leaks and ensure proper chest tube function.' This is the most important assessment for a client with a chest tube post-surgery because it ensures that the chest tube is functioning properly. Checking for air leaks helps prevent complications such as pneumothorax or hemothorax. Choice A is incorrect because clamping the chest tube periodically can lead to serious complications and should not be done unless specifically ordered by a healthcare provider. Choice C is important for promoting lung expansion but is not the most critical assessment related to the chest tube. Choice D is also important for respiratory function but is not the priority when assessing a chest tube post-surgery.