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.
You may also like to solve these questions
A nurse is caring for a client who has COPD. Which of the following findings require immediate follow-up?
- A. Client is oriented to person, place, and time.
- B. Client is restless.
- C. Pupils are reactive to light.
- D. Client is tachypneic, cough is productive, and mucous is yellow in color.
- E. Wheezes and crackles heard upon auscultation.
Correct Answer: D
Rationale: The correct answer is D. Tachypnea, productive cough with yellow mucus in a client with COPD indicate a potential exacerbation requiring immediate follow-up. Tachypnea suggests respiratory distress, while yellow mucus may indicate infection. Prompt intervention can prevent worsening respiratory status. Choices A, B, and C do not indicate acute respiratory distress. Option E may be concerning but doesn't necessitate immediate intervention like option D does.
A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?
- A. NG tube
- B. Tongue blade
- C. Wrist restraints
- D. Oral airway
Correct Answer: D
Rationale: The correct answer is D: Oral airway. During a seizure, a client may experience difficulty breathing due to their airway being obstructed. Placing an oral airway helps maintain a clear airway, ensuring adequate oxygenation. NG tube (A) is not relevant to managing seizures. Tongue blade (B) can cause injury during a seizure. Wrist restraints (C) are not appropriate and can increase the risk of injury.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice D) is common after a chest tube insertion and can be managed with pain medication.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
- A. Photophobia
- B. Bradycardia
- C. Intermittent headache
- D. Petechiae on the chest
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord. Photophobia, or sensitivity to light, is a classic symptom of meningitis due to the irritation of the meninges causing increased sensitivity to light. This occurs because the inflamed meninges lead to stimulation of the nerves around the brain, resulting in discomfort when exposed to light.
Bradycardia (B) is not typically associated with meningitis. Intermittent headache (C) is vague and can be present in various conditions. Petechiae on the chest (D) are more commonly seen in conditions like meningococcal meningitis.
A nurse is providing teaching to a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching?
- A. Take stimulant laxatives daily to relieve constipation.
- B. Avoid fiber-rich foods to prevent bloating.
- C. Increase water intake and use bulk-forming laxatives.
- D. Eat a low-carbohydrate diet to reduce symptoms.
Correct Answer: C
Rationale: Correct Answer: C. Increase water intake and use bulk-forming laxatives.
Rationale: Increasing water intake helps soften stool, easing constipation in IBS-C. Bulk-forming laxatives add fiber to stool, improving bowel movements. Stimulant laxatives (A) can lead to dependency. Avoiding fiber-rich foods (B) worsens constipation. A low-carbohydrate diet (D) may exacerbate constipation.