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A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia. The first action the nurse should take is to...
- A. notify the provider of increased pain followed by elevating the extremity at level of the heart.
- B. check the client's oxygen saturation followed by administering pain medication.
- C. assess the client's incision site followed by applying a cold pack.
- D. monitor the client's vital signs followed by documenting the findings.
Correct Answer: A
Rationale: Post-ORIF, increased pain (Day 2, 1600) suggests compartment syndrome, a surgical emergency requiring immediate provider notification to evaluate for fasciotomy. Elevating the extremity at heart level balances perfusion without worsening pressure, unlike high elevation which reduces blood flow. Checking oxygen saturation and medicating pain address symptoms, not the cause pain here signals ischemia, not hypoxia. Assessing the incision (e.g., swelling) supports suspicion, but notification trumps delay; cold packs may mask signs. Monitoring vital signs is routine, but pain's acuity demands action over documentation. Prompt reporting aligns with the 6 Ps, prioritizing limb salvage, making it the critical first step.
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A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client consumed citrus juice 3 days before the test.
- B. The client takes ibuprofen for headaches.
- C. The client had a hemorrhoidectomy 1 year ago.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Fecal occult blood tests detect heme, but false positives arise from non-colonic bleeding. Ibuprofen, an NSAID, irritates the GI mucosa, causing microbleeds that mimic colorectal sources, a known confounder clients are advised to stop it pre-test. Citrus juice may cause false negatives (vitamin C interferes with guaiac reaction), not positives, and 3 days minimizes impact. A hemorrhoidectomy 1 year ago, healed, doesn't bleed unless recurrent, not suggested. Breast cancer doesn't affect GI bleeding unless metastatic, unlikely here. Ibuprofen's GI effect aligns with testing pitfalls (e.g., ACG guidelines), making it the likely false-positive source to identify.
A nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take? (Select all that apply.)
- A. Maintain skin integrity over the blisters
- B. Apply ice to the larger blisters.
- C. Administer ibuprofen for pain.
- D. Run cool water over the affected area.
- E. Allow the affected area to remain open to air.
Correct Answer: A,C,D
Rationale: Preserving blisters (A), giving ibuprofen (C), and using cool water (D) are appropriate. Ice risks further injury, and leaving it open isn't ideal for initial care.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4
Medical History
Today, 0700:
Admitting Diagnosis: Heart Failure
Past medical history of heart failure, coronary artery disease, sleep apnea
Client reports diarrhea, dry mouth, and unusual thirst for the past three days
A nurse is assisting in the care of a male client who has a new prescription for furosemide. Which of the following client findings should the nurse identify as a contraindication to the administration of furosemide?
- A. Potassium level
- B. Blood pressure
- C. Prescription for digoxin
- D. Client verbal report
- E. BUN
Correct Answer: A
Rationale: Furosemide, a loop diuretic, treats heart failure but depletes potassium, risking hypokalemia. A low potassium level (e.g., <3.5 mEq/L) contraindicates its use hypokalemia causes arrhythmias, especially with heart failure's cardiac strain, per pharmacology standards. Blood pressure matters hypotension may worsen with diuresis but isn't a direct contraindication unless extreme. Digoxin use heightens hypokalemia risk (enhancing toxicity), but potassium level drives the decision. The client's report of diarrhea and thirst suggests dehydration, a caution, not a strict contraindication. Low potassium demands correction (e.g., supplements) before furosemide, preventing lethal complications like ventricular fibrillation, making it the critical finding to identify.
A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?
- A. Confusion
- B. Hypothermia
- C. Referred pain in the right shoulder
- D. Orange colored urine
- E. Fever
- F. Dysuria
- G. Urgency
Correct Answer: A
Rationale: Confusion is common in older adults with cystitis due to altered mental status from infection.
A nurse is collecting data from a client who has hyperthyroidism and is taking propylthiouracil. Which of the following statements by the client indicates the medication is effective?
- A. I continue to lose weight.
- B. I have less oily skin.
- C. I no longer feel nervous.
- D. I no longer take a stool softener.
- E. I feel more tired.
- F. My appetite has decreased.
- G. My heart rate is faster.
Correct Answer: C
Rationale: Reduced nervousness indicates propylthiouracil is controlling hyperthyroid symptoms like anxiety.