Nokea
A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement?
- A. Provide an overhead trapeze to the bed for the client to use
- B. Assist the client with repositioning every hour to prevent discomfort.
- C. Encourage the client to use a bedpan instead of getting up to the bathroom.
- D. Offer additional pain medication to help the client relax.
Correct Answer: A
Rationale: An overhead trapeze allows the client to reposition independently, promoting autonomy and reducing frustration.
You may also like to solve these questions
A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care?
- A. Altered urinary elimination
- B. Impaired gas exchange
- C. Fluid volume excess
- D. Decreased cardiac output
Correct Answer: C
Rationale: Hyponatremia (low sodium level) is often associated with fluid volume excess in clients with lung carcinoma.
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
- A. Black ulcers and dependent rubor
- B. Irregular ulcer shapes and severe edema
- C. Absent pedal pulses and shiny skin
- D. Hairless lower extremities and cool feet
Correct Answer: B
Rationale: Venous ulcers are typically irregular in shape and associated with severe edema, while arterial ulcers are more likely to present with absent pulses and cool extremities.
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery?
- A. Administration of IV furosemide (Lasix)
- B. Initiation of an external pacemaker
- C. Assistance with endotracheal intubation
- D. Placement of central venous access
Correct Answer: B
Rationale: An 80% blockage of the RCA can lead to bradycardia or heart block. An external pacemaker may be needed to maintain adequate heart rate and cardiac output.
Which physiological changes occur as a result of hypoxemia in congestive heart failure (CHF)?
- A. Polycythemia and clubbing
- B. Anemia and barrel chest
- C. Increased white blood cells and low platelets
- D. Elevated erythrocyte sedimentation rate and peripheral edema
Correct Answer: A
Rationale: Hypoxemia stimulates erythropoiesis, causing polycythemia, which along with chronic hypoxemia can lead to digital clubbing.
What is one of the most frequent causes of hypovolemic shock in children?
- A. Sepsis
- B. Blood loss
- C. Anaphylaxis
- D. Congenital heart disease
Correct Answer: B
Rationale: Blood loss is the most frequent cause of hypovolemic shock in children. Sepsis causes septic shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Congenital heart disease contributes to hypervolemia, not hypovolemia.