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 action for the nurse to take is to reapply the weights to ensure proper traction. This is crucial to maintain the intended pulling force required for the skeletal traction to be effective in realigning the fractured bone. If the weights are resting on the floor, it means that the traction is not being applied as intended, which can lead to ineffective treatment and potential complications. Removing a weight (choice A) would decrease the traction force, tying knots in the ropes (choice B) would alter the mechanics of the system, and increasing the elevation of the extremity (choice C) would not address the issue of weights resting on the floor. Therefore, the best course of action is to reapply the weights to ensure proper traction and alignment of the fractured bone.
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A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Chloride level
- B. Creatinine kinase
- C. Uric acid
- D. Intrinsic factor
Correct Answer: C
Rationale: The correct answer is C: Uric acid. In acute gout, there is an increase in uric acid levels due to the deposition of urate crystals in the joints, causing inflammation and pain. Elevated uric acid levels are a hallmark of gout.
A: Chloride level is not directly related to acute gout.
B: Creatinine kinase is a marker of muscle damage, not specific to gout.
D: Intrinsic factor is related to vitamin B12 absorption, not gout.
Therefore, the nurse should expect an increase in uric acid levels as the most appropriate laboratory result in a client with acute gout.
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?
- A. Oxygen saturation
- B. Warm extremities
- C. Temperature
- D. Level of pain
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation. Ensuring adequate oxygen saturation is the nurse's priority because the client received moderate sedation, which can depress the respiratory drive. Monitoring oxygen saturation helps to detect any signs of respiratory distress early on. Warm extremities (B) and temperature (C) are important but not the priority in this situation. Pain management (D) is important but not as critical as ensuring adequate oxygenation.
A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
- A. Crackles
- B. Decreased urine output
- C. Daytime oliguria
- D. Halo vision
Correct Answer: A
Rationale: The correct answer is A: Crackles. Left-sided heart failure causes fluid buildup in the lungs, leading to pulmonary congestion. Crackles are indicative of fluid in the alveoli, a common sign of pulmonary edema in heart failure. Decreased urine output (B), daytime oliguria (C), and halo vision (D) are not specific to left-sided heart failure. Decreased urine output and oliguria are more associated with kidney dysfunction, while halo vision is related to eye conditions like cataracts.
A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
- A. Blood glucose of 110 mg/dL
- B. Decrease in blood pressure
- C. Increase in urinary output
- D. Respiratory rate of 10/min
Correct Answer: B
Rationale: The correct answer is B: Decrease in blood pressure. Telmisartan is an angiotensin II receptor blocker used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would indicate that the medication has been effective. Choice A, blood glucose of 110 mg/dL, is unrelated to the action of telmisartan. Choice C, increase in urinary output, is not a direct effect of telmisartan. Choice D, respiratory rate of 10/min, is not a typical indicator of the effectiveness of telmisartan in managing hypertension.
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
- A. Loss of hearing
- B. Paresthesia
- C. Muscle wasting
- D. Changes in vision
Correct Answer: B
Rationale: The correct answer is B: Paresthesia. Pernicious anemia leads to Vitamin B12 deficiency, causing nerve damage and paresthesia (tingling or burning sensation). This poses a risk to the client's safety as it can affect their balance and coordination, increasing the risk of falls and injuries. Loss of hearing (A), muscle wasting (C), and changes in vision (D) are potential manifestations of pernicious anemia but do not directly pose a risk to safety like paresthesia.