Nokea
A nurse at an outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?
- A. A home health patient reports, "I am starting to have a breakdown of my heels."?
- B. A patient that received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today."?
- C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
- D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'
Correct Answer: B
Rationale: The correct answer is the patient who received an upper extremity cast yesterday and reports not being able to feel their fingers in the right hand. This situation indicates a potential neurovascular issue that requires immediate attention to prevent complications. The other options are of lesser priority: A - Breakdown of the heels, while concerning, is not an acute issue that necessitates immediate intervention. C - An ankle sprain that occurred two weeks ago is now subacute and unlikely to be an urgent medical concern. D - Pain in the knee following a total knee replacement (TKR) is common in the early postoperative period and is not unexpected.
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A person who had a left CVA and right lower extremity hemiparesis is being instructed by a nurse to use a quad cane. Which of the following is the most appropriate gait sequence?
- A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
- C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
Correct Answer: A
Rationale: The correct gait sequence for a person with left CVA and right lower extremity hemiparesis using a quad cane is to place the cane in the patient's strong upper extremity, which is the left upper extremity in this case. The correct sequence should be right lower extremity followed by left upper extremity, as this pattern mimics a normal gait pattern. Therefore, Choice A is the correct answer. Choices B, C, and D are incorrect because they do not follow the proper gait sequence for this specific patient's condition. The cane should be placed in the strong upper extremity, and the affected lower extremity should move first to provide stability and support, which is essential in this situation.
In hanging a parenteral IV fluid that is to be infused by gravity, rather than with an infusion pump, the nurse notes that the IV tubing is available in different drop factors. Which tubing is a microdrop set?
- A. 15 drops per milliliter
- B. 60 drops per milliliter
- C. 20 drops per milliliter
- D. 10 drops per milliliter
Correct Answer: B
Rationale: A microdrop set delivers 60 drops per milliliter of IV fluid. This allows for a more precise control of the infusion rate. The correct choice is B because it provides the desired microdrop rate. Choices A, C, and D are incorrect. A delivers 15 drops per milliliter, which is a macrodrop set. C delivers 20 drops per milliliter, also a macrodrop set. D delivers 10 drops per milliliter, another macrodrop set. Therefore, the correct choice for a microdrop set is B.
A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?
- A. Reassure the patient that pain is normal following surgery.
- B. Administer prn Nifedipine and assess the client's response.
- C. Administer prn Meperidine HCL and assess the client's response.
- D. Recheck BP and pulse rate every 20 minutes for the next hour.
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.
The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:
- A. use cold applications to the sprain during the first 24-48 hours.
- B. expect disability to decrease within the first 24 hours of injury
- C. expect pain to decrease within 3 hours after injury.
- D. begin progressive passive and active range of motion exercises immediately.
Correct Answer: A
Rationale: When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24-48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice B) is incorrect as disability and pain are anticipated to increase during the first 2-3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice D) is not recommended; these exercises are usually started 2-5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.
A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur?
- A. hyperkalemia
- B. hypernatremia
- C. hypokalemia
- D. hypomagnesemia
Correct Answer: C
Rationale: When a client is receiving drug therapy with furosemide and digitalis, the nurse should anticipate the development of hypokalemia due to the potassium-wasting effects of furosemide. Hypokalemia can potentiate digitalis toxicity. While hyperkalemia is a concern with some medications, it is not typically associated with furosemide and digitalis. Furosemide can lead to hyponatremia, not hypernatremia, due to its diuretic effect. Hypomagnesemia, though a possible imbalance, is not the most likely to occur in this scenario as furosemide and digitalis are more commonly associated with hypokalemia.