Nokea
A nurse has been ordered to set up Buck's traction on a patient's lower extremity due to a femur fracture. Which of the following applies to Buck's traction?
- A. A weight greater than 10 lbs. should be used.
- B. The line of pull is upward at an angle.
- C. The line of pull is straight
- D. A weight greater than 20 lbs. should be used.
Correct Answer: C
Rationale: The correct answer is that the line of pull is straight for Buck's traction. This type of traction is applied to maintain alignment and immobilization of fractures, typically involving the lower extremities. A straight line of pull helps to provide the necessary countertraction to keep the fractured bone in proper alignment. Choices A and D are incorrect because Buck's traction commonly uses a weight range between 5-10 lbs, and using a weight greater than 10 or 20 lbs would not be appropriate or safe. Choice B is incorrect as well since the line of pull for Buck's traction is straight, not upward at an angle.
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A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63mmHg, HCO3 23, and oxygenation saturation (SAO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?
- A. tuberculosis (TB)
- B. pneumonia
- C. pleural effusion
- D. hypoxia
Correct Answer: D
Rationale: A combined low PO2 and low SAO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. In pneumonia, the PO2 and PCO2 might be low because hypoxia stimulates hyperventilation, but the best analysis in this case is hypoxia due to the combination of low PO2 and low SAO2.
A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?
- A. Note in medication records the drug given
- B. The client was not hurt, no need for documentation
- C. Note the client's orientation
- D. Completely fill out an incident report
Correct Answer: D
Rationale: In the case where medications are given to the wrong client, the appropriate documentation by the nurse should involve completely filling out an incident report. This report is essential for tracking errors, implementing corrective measures, and ensuring patient safety. Choice A is incorrect because solely noting the drug given does not address the severity of the error. Choice B is incorrect because even if the client was not hurt, documentation is crucial for quality improvement and risk prevention. Choice C is incorrect as noting the client's orientation does not adequately address the medication error and its implications.
Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?
- A. Dizziness and orthostatic hypotension.
- B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
- C. Drowsiness, lethargy, and fatigue.
- D. Neuropathy and tingling in the extremities.
Correct Answer: B
Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.
A nurse reviewed the arterial blood gas reading of a 25-year-old male. The nurse should be able to conclude the patient is experiencing which of the following conditions?
- A. metabolic acidosis
- B. respiratory acidosis
- C. metabolic alkalosis
- D. respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is respiratory alkalosis. In respiratory alkalosis, there is an elevated pH and low carbon dioxide levels (PaCO2 < 35 mmHg). In the given arterial blood gas reading, the patient's pH is 7.41 (within normal range), PaCO2 is 29 mmHg (below normal range), indicating respiratory alkalosis. The bicarbonate level is normal (25 mEq/l), ruling out metabolic acidosis or alkalosis. The low PaO2 (54 mmHg) may indicate hypoxemia, but it is not directly related to the acid-base disorder being assessed. Metabolic acidosis (choice A) is characterized by low pH and low bicarbonate levels, which are not present in this case. Respiratory acidosis (choice B) is indicated by low pH and high PaCO2 levels, which also do not match the provided data. Metabolic alkalosis (choice C) is defined by high pH and high bicarbonate levels, which are not seen in this scenario.
A 55-year-old female asks a nurse the following, “Which mineral/vitamin is the most important to prevent the progression of osteoporosis?†The nurse should state:
- A. Potassium
- B. Magnesium
- C. Calcium
- D. Vitamin B12
Correct Answer: C
Rationale: The correct answer is C: Calcium. Calcium is essential for maintaining bone health and is crucial in preventing osteoporosis. Adequate calcium intake, along with vitamin D, is vital for bone strength. While other minerals and vitamins are also important for overall health, in the context of preventing osteoporosis, calcium plays a primary role. Potassium (Choice A), Magnesium (Choice B), and Vitamin B12 (Choice D) are important for various bodily functions but are not as directly linked to preventing osteoporosis as calcium.