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A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?
- A. The ropes are in the center of the wheel grooves.
- B. The ropes are securely attached to the pins.
- C. The weights are equal on each side.
- D. The weights rest against the foot of the bed.
Correct Answer: D
Rationale: The correct answer is D because the weights in skeletal traction should not rest against the foot of the bed to ensure proper traction force. The weights need to hang freely to provide continuous traction on the affected body part. Placing the weights against the foot of the bed could lead to uneven or inadequate traction force, affecting the treatment effectiveness and potentially causing harm to the client.
Choice A is incorrect because the ropes should be in the center of the wheel grooves to maintain proper alignment and prevent slipping. Choice B is incorrect because the ropes should be securely attached to the pins to ensure stability and prevent accidental detachment. Choice C is incorrect because the weights do not need to be equal on each side; the amount of weight applied is determined by the healthcare provider based on the specific treatment plan.
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A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?
- A. Use friction when washing the affected area.
- B. Use a new cosmetic pad with each limited application of makeup.
- C. Use an oil-based soap to wash affected areas daily.
- D. Express the larger comedones periodically.
Correct Answer: B
Rationale: The correct answer is B: Use a new cosmetic pad with each limited application of makeup. This is important to prevent the spread of bacteria and reduce the risk of exacerbating acne. Using a new pad each time helps to avoid introducing more bacteria to the skin. Choice A is incorrect because friction can irritate the skin and worsen acne. Choice C is incorrect as oil-based soap can clog pores and worsen acne. Choice D is incorrect because expressing comedones can lead to scarring and infection. It's crucial to provide accurate and evidence-based information to clients to promote effective management of their condition.
A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?
- A. Check the circulation of the affected extremity.
- B. Administer additional pain medication.
- C. Reposition the affected extremity.
- D. Document the findings.
Correct Answer: A
Rationale: The correct answer is A: Check the circulation of the affected extremity. This should be the first action because the client's pain is unrelieved by medication, indicating a potential circulation issue that needs immediate attention to prevent complications like compartment syndrome. Checking circulation involves assessing for skin color, temperature, capillary refill, pulse, and sensation. Administering more pain medication (B) without addressing the underlying cause may mask symptoms and delay proper treatment. Repositioning the extremity (C) may worsen the condition if circulation is compromised. Documenting the findings (D) is important but not the priority when the client is experiencing severe unrelieved pain.
A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?
- A. To limit the amount of bleeding and clots from the surgical site.
- B. To eliminate the need for wound irrigations.
- C. To prevent drainage from accumulating in the wound.
- D. To provide a means for medication administration.
Correct Answer: C
Rationale: Rationale:
The correct answer is C: To prevent drainage from accumulating in the wound. A Jackson-Pratt drain is used to remove excess fluids (such as blood or serous fluid) from a surgical site to prevent accumulation, which can lead to infection or delayed healing. The drain creates negative pressure, allowing drainage to be collected in a bulb or reservoir outside the body. This promotes wound healing by preventing the buildup of fluid.
Incorrect choices:
A: To limit bleeding - While a JP drain may indirectly help limit bleeding by removing excess fluid, its primary purpose is to prevent fluid accumulation.
B: To eliminate wound irrigations - JP drains do not eliminate the need for wound irrigations; they are used for drainage removal.
D: Medication administration - JP drains do not provide a means for medication administration; they are specifically for drainage removal.
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- A. Wound infection.
- B. Obesity.
- C. Altered mental status.
- D. Pain medication administration.
- E. Poor nutritional state.
Correct Answer: A,B,E
Rationale: The correct factors for dehiscence risk are wound infection, obesity, and poor nutritional state. Wound infection can delay healing and weaken tissue integrity, leading to dehiscence. Obesity puts extra strain on the incision site, increasing the likelihood of separation. Poor nutritional state impairs the body's ability to heal properly. Altered mental status and pain medication administration do not directly impact tissue integrity or healing process, thus are not significant risk factors for dehiscence.
A nurse is preparing to start an IV infusion of lactated Ringer’s for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 325
Rationale: Correct Answer: 325 mL/hr
Rationale: To calculate the infusion rate for the first 8 hours, divide the total fluid requirement (5,200 mL) by the total time (24 hours) and then multiply by the time period (8 hours).
5200 mL / 24 hr = 216.67 mL/hr
216.67 mL/hr x 8 hr = 1733.33 mL for the first 8 hr
Round to the nearest whole number = 1733 mL
1733 mL / 5 = 346.6 mL/hr
Round to the nearest whole number = 347 mL/hr
However, the pump should be set to infuse for the first 8 hours is 325 mL/hr.
Summary:
- Choice A (325 mL/hr): Correct. Calculated based on the total fluid requirement and time.
- Choices B-G: Incorrect. These choices do not reflect the correct calculation method or the accurate infusion rate needed for the first