Nokea
A nurse is caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take?
- A. Use a hair dryer to blow hot air into the cast to relieve itching.
- B. Perform neurovascular checks of the affected extremity every 2 hr.
- C. Position the fractured arm below the level of the client's heart.
- D. Immobilize the client's fingers using a hand splint.
Correct Answer: B
Rationale: Neurovascular checks every 2 hours assess circulation and nerve function, critical after cast application. Hot air can burn, elevation reduces swelling, and finger immobilization isn't standard unless specified.
You may also like to solve these questions
A nurse is collecting data from a client who has heart failure. Which of the following findings should the nurse report to the provider?
- A. Activity tolerance
- B. Weight
- C. Chest x-ray results
- D. Echocardiogram results
Correct Answer: B
Rationale: Heart failure management hinges on detecting decompensation, where weight gain from fluid retention is a red flag. Sudden increases (e.g., 2-3 lbs overnight) signal worsening congestion, necessitating prompt provider action like diuretic adjustment. Activity tolerance reflects functional status but is subjective and less urgent unless acutely dropping. Chest x-ray results show pulmonary edema or cardiomegaly, but weight offers earlier, actionable data. Echocardiogram results assess heart function long-term, not immediate changes. Daily weight monitoring is a cornerstone of heart failure care fluid overload precedes symptoms like dyspnea, making it the priority to report. This aligns with clinical guidelines (e.g., ACC/AHA), enabling timely intervention to prevent hospitalization or acute failure, emphasizing its critical role in ongoing assessment.
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?
- A. Distended neck veins
- B. Polyuria
- C. Vomiting
- D. Hypertension
- E. Fever and chills
- F. Tachycardia
- G. Hypotension
Correct Answer: C
Rationale: Vomiting is a sign of a septic reaction due to contaminated blood; distended veins suggest fluid overload, polyuria isn't typical, and hypertension isn't specific.
A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?
- A. Absence of Chvostek's sign
- B. Presence of Kussmaul respirations
- C. Presence of diaphoresis
- D. Absence of urinary ketones
Correct Answer: B
Rationale: Kussmaul respirations indicate hyperglycemia-induced metabolic acidosis as the body compensates for high glucose. Chvostek's is unrelated, diaphoresis suggests hypoglycemia, and ketones may be present but aren't definitive here.
A home health nurse is assisting in the care of a client following a modified radical mastectomy. Which of the following statements by the client indicates effective coping?
- A. I would like to see what this looks like today.
- B. I would just like to spend my day staring at the TV.
- C. I'm going to close my eyes until you are done dressing my incision.
- D. I'm planning to stay at home until my breast reconstructive surgery.
- E. I don't care about my appearance anymore.
- F. I'll never leave the house again.
- G. I feel fine and don't need help.
Correct Answer: A
Rationale: Wanting to see the incision shows acceptance and engagement in recovery; other options suggest avoidance or denial.
A nurse is reinforcing teaching for a client who was admitted with an exacerbation of COPD. Which of the following should the nurse include in the client teaching?
- A. You should consume small, frequent meals each day.
- B. You should decrease your caloric intake by 200 calories per day.
- C. You should increase your oxygen to 5 liters per minute if you have shortness of breath.
- D. You should discontinue your prednisone when your symptoms improve.
Correct Answer: A
Rationale: Small, frequent meals reduce diaphragm pressure and breathing effort in COPD. Caloric reduction isn't advised, oxygen adjustments need orders, and prednisone requires tapering.