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A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessments should be the nurse's priority?
- A. Neurovascular assessment
- B. Braden scale
- C. Pain assessment
- D. Morse Fall Risk scale
Correct Answer: A
Rationale: The correct answer is A: Neurovascular assessment. This is the priority because the client is postoperative following ORIF of the femur, which puts them at risk for impaired circulation and nerve damage. The nurse needs to assess for signs of compromised blood flow or nerve function, such as changes in sensation, color, temperature, or pulse in the affected limb. If left unaddressed, neurovascular complications can lead to serious consequences like compartment syndrome or permanent damage. The other options are not the priority in this situation: B (Braden scale) assesses risk for pressure ulcers, C (Pain assessment) is important but not the priority over neurovascular status, and D (Morse Fall Risk scale) assesses fall risk which is important but not the priority immediately post-ORIF.
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A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
- A. Make sure the client's room has positive pressure airflow.
- B. Make sure dietary plates and utensils are disposable.
- C. Wear an N95 respirator when providing direct client care.
- D. Monitor the client's temperature once every 6 hr.
Correct Answer: A
Rationale: Correct Answer: A: Make sure the client's room has positive pressure airflow.
Rationale:
1. Positive pressure airflow prevents contaminated air from entering the room, reducing the risk of infections.
2. It helps maintain a clean environment by keeping airborne pathogens out.
3. Protects the client who has a compromised immune system post-transplant.
Summary of Incorrect Choices:
B: Disposable utensils are important but do not directly protect the client from airborne infections.
C: N95 respirators are for the healthcare provider's protection, not the client's.
D: Monitoring temperature is essential but does not directly prevent infections in a protective isolation setting.
A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement?
- A. Initiate airborne precautions
- B. Ensure the clients bed is positioned to greater than 45°
- C. Encourage frequent ambulation
- D. Ensure lights are dimmed in the clients room
Correct Answer: D
Rationale: The correct answer is D: Ensure lights are dimmed in the client's room. Dimming the lights can help decrease stimulation and minimize discomfort for a client with bacterial meningitis, as they may be sensitive to light due to photophobia, which is a common symptom in meningitis. It can also help reduce the risk of exacerbating headaches and other symptoms.
Incorrect choices:
A: Initiating airborne precautions is not necessary for bacterial meningitis, as it is not transmitted through the air.
B: Ensuring the client's bed is positioned to greater than 45° is not directly related to the care of a client with bacterial meningitis.
C: Encouraging frequent ambulation may not be appropriate for a client with bacterial meningitis, as they may be too weak or ill to ambulate.
E, F, G: There are no additional choices provided, but they would likely be incorrect as they are not relevant to the care of a client with bacterial meningitis.
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. Chronic level
- B. Creatinine kinase
- C. Uric acid
- D. Immac factor
Correct Answer: C
Rationale: The correct answer is C: Uric acid. In acute gout, there is an increase in the production or decrease in the excretion of uric acid, leading to elevated levels in the blood. This results in the formation of urate crystals in the joints, causing inflammation and pain. Choices A, B, and D are unrelated to acute gout. A chronic level (Choice A) does not indicate an acute condition. Creatinine kinase (Choice B) is an enzyme related to muscle damage, not specific to gout. Immac factor (Choice D) is not a relevant marker for acute gout. Therefore, the correct answer is C as it directly correlates with the pathophysiology of acute gout.
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
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. Gag reflex
- B. Warmth of extremities
- C. Temperature
- D. Level of pain
Correct Answer: A
Rationale: The correct answer is A: Gag reflex. The priority assessment for a client post-endoscopy with sedation is to ensure their airway is intact. The presence of a gag reflex indicates the airway protection mechanism is functional, reducing the risk of aspiration. Monitoring warmth of extremities, temperature, and pain level are important but secondary assessments compared to airway patency. Ensuring the client's safety and preventing respiratory compromise take precedence in this situation.