Nokea
A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?
- A. Remove one of the weights.
- B. Tie knots in the ropes near the pulleys to shorten them.
- C. Increase the elevation of the affected extremity.
- D. Reapply the weights to ensure proper traction.
Correct Answer: D
Rationale: The correct answer is D: Reapply the weights to ensure proper traction. When the weights are resting on the floor, it means that there is no longer effective traction on the affected limb. To maintain proper skeletal traction, the weights should be suspended freely in the air. By reapplying the weights and ensuring they are hanging freely, the nurse can restore the necessary traction force to immobilize the fractured bone and facilitate healing. Removing a weight (choice A) may compromise the traction. Tying knots in the ropes (choice B) may alter the mechanics of the traction system. Increasing the elevation of the extremity (choice C) does not address the issue of the weights resting on the floor.
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Which actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increased dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The nurse should anticipate cardiac catheterization prep (A) to ensure client readiness. Continuous heparin infusion (B) prevents clot formation during the procedure. Increased metoprolol dosage (D) may be needed for cardiac stability. NPO status (E) is crucial to prevent complications during the procedure. Ambulation (C) may be contraindicated due to the invasive nature of the procedure. Antibiotics (F) are not routinely needed for cardiac catheterization prep.
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
- A. Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
- B. Decrease in heart rate to 120 bpm
- C. Rapid
- D. shallow respirations
- E. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg. Cushing's triad is a set of three classic signs indicating increased intracranial pressure (ICP). The triad includes hypertension (widening pulse pressure), bradycardia, and irregular respirations. In this case, an increase in blood pressure is consistent with the hypertension component of Cushing's triad. This occurs due to the body's compensatory mechanism to maintain perfusion to the brain in response to increased ICP. Choices B, C, D, and E do not align with the classic signs of Cushing's triad. Bradycardia, not a decrease in heart rate, is typically seen in Cushing's triad. Rapid and shallow respirations are not part of the triad. Hypotension is not a characteristic finding in Cushing's triad.
A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?
- A. Teach the client how to self-medicate using the PCA device.
- B. Encourage family members to press the PCA button for the client.
- C. Monitor the client's respiratory status every 4 hr.
- D. Administer an oral opioid for breakthrough pain.
Correct Answer: A
Rationale: The correct answer is A. Teaching the client how to self-medicate using the PCA device is essential to empower the client in managing their pain effectively. This promotes autonomy and ensures the client receives the appropriate dose at the right time, enhancing pain control. Choice B is incorrect as family members should not press the PCA button for the client to maintain safety and prevent medication errors. Choice C is incorrect as respiratory status should be monitored more frequently, ideally every 1-2 hours, when a client is receiving opioids due to the risk of respiratory depression. Choice D is incorrect as administering an oral opioid for breakthrough pain may lead to overdose or adverse effects when already receiving morphine through PCA.
A nurse is caring for a client who is experiencing diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
- A. Check potassium levels.
- B. Begin bicarbonate continuous IV infusion.
- C. Initiate a continuous IV insulin infusion.
- D. Administer 0.9% sodium chloride.
Correct Answer: D
Rationale: The correct answer is D: Administer 0.9% sodium chloride. The priority intervention in DKA is fluid resuscitation to correct dehydration and electrolyte imbalances. 0.9% sodium chloride helps restore intravascular volume and improves kidney perfusion. Checking potassium levels (A) is important but can wait until after fluid resuscitation. Beginning bicarbonate infusion (B) is not recommended as it can worsen acidosis. Initiating continuous IV insulin infusion (C) is important but should follow fluid resuscitation. Administering 0.9% sodium chloride takes precedence in managing DKA.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an excess of carbon dioxide (CO2) in the blood, leading to a decrease in pH. This imbalance occurs when the lungs are unable to eliminate enough CO2 through respiration, causing it to accumulate in the bloodstream. This excess CO2 combines with water in the blood to form carbonic acid, leading to acidosis. Choices B, C, and D are incorrect as they do not directly relate to the accumulation of CO2 in respiratory acidosis. Loss of bicarbonate (B) would lead to metabolic acidosis, excessive vomiting (C) would cause metabolic alkalosis, and hyperventilation (D) would actually help in decreasing CO2 levels, which is not the case in respiratory acidosis.