Nokea
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse?
- A. The client's capillary refill in the left toe is 6 seconds.
- B. The client has 100 mL blood in the closed-suction drain.
- C. The client has an oral temperature of 38.3°C (100.9°F).
- D. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
Correct Answer: A
Rationale: The correct answer is A because a capillary refill of 6 seconds in the left toe indicates poor circulation, which could lead to ischemia or necrosis in the extremity. Immediate intervention is necessary to prevent further complications.
Choice B is not as urgent as it involves monitoring and managing drainage, which can be addressed after the circulation concern is addressed.
Choice C, an elevated temperature, may indicate infection but is not as immediately life-threatening as poor circulation.
Choice D, pain at the operative site, is important but does not require immediate intervention as it can be managed with pain medication.
You may also like to solve these questions
A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
- A. Oily skin
- B. Alopecia
- C. Increased salivation
- D. Diplopia
Correct Answer: B
Rationale: The correct answer is B: Alopecia. Alopecia, or hair loss, is a common manifestation of malnutrition due to inadequate intake of essential nutrients. Malnutrition can lead to hair thinning and loss. Oily skin (A) is more commonly associated with excess intake of fats. Increased salivation (C) is not a typical manifestation of malnutrition. Diplopia (D), or double vision, is not directly related to malnutrition.
A nurse is planning care for a client who has *Clostridium difficile* gastroenteritis. Which of the following is an appropriate nursing action?
- A. Place the client in a protective environment
- B. Clean surfaces with chlorhexidine
- C. Obtain a stool specimen with gloves
- D. Wash hands with alcohol-based hand rub
Correct Answer: C
Rationale: The correct answer is C: Obtain a stool specimen with gloves.
Rationale:
1. Clostridium difficile is transmitted through contact with feces, so obtaining a stool specimen with gloves is essential to prevent the spread of infection.
2. Using gloves during specimen collection reduces the risk of contaminating hands and surfaces.
3. It is important to identify the specific pathogen causing the gastroenteritis to determine the appropriate treatment.
Summary of incorrect choices:
A: Placing the client in a protective environment is not necessary for Clostridium difficile gastroenteritis.
B: Cleaning surfaces with chlorhexidine is important for infection control but not the most appropriate action in this scenario.
D: Washing hands with alcohol-based hand rub is important for general infection control but not specific to obtaining a stool specimen.
Overall, choice C is the most relevant and appropriate nursing action in this situation.
A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?
- A. I break out in a rash when I eat strawberries
- B. I often have diarrhea after eating scrambled eggs
- C. I have trouble urinating if I eat acidic foods
- D. I sometimes start to wheeze when I eat peanuts
Correct Answer: A
Rationale: The correct answer is A because a client who experiences a rash when eating strawberries may have a latex allergy due to cross-reactivity between latex and certain fruits like strawberries. This is known as latex-fruit syndrome. The other choices (B, C, D) do not indicate a potential latex allergy and are unrelated symptoms. It's important for the nurse to recognize this risk factor to prevent an allergic reaction during surgery.
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Painless vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Painless vaginal bleeding. Cervical cancer can present with abnormal vaginal bleeding, which may include bleeding between periods, after intercourse, or post-menopause. This is due to the abnormal growth of cells in the cervix. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typical manifestations of cervical cancer. Diarrhea and urinary hesitancy are more commonly associated with gastrointestinal or urinary tract issues, while unexplained weight gain can be linked to various factors such as hormonal imbalances or dietary changes.
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
- A. Discard the radioactive device in the client's trash can.
- B. Limit time for visitors to 2 hr per day.
- C. Instruct visitors to remain 3 feet from the client.
- D. Keep soiled bed linens in the client's room.
Correct Answer: C
Rationale: The correct answer is C: Instruct visitors to remain 3 feet from the client. This is because brachytherapy involves the internal placement of radioactive sources close to the tumor. By instructing visitors to remain 3 feet away, the nurse helps minimize their exposure to radiation.
A: Discarding the radioactive device in the client's trash can is incorrect as it can pose a radiation hazard to others.
B: Limiting time for visitors to 2 hours per day does not directly address radiation exposure concerns.
D: Keeping soiled bed linens in the client's room does not address radiation safety for visitors.
In summary, option C is the best choice as it directly addresses radiation safety for visitors during brachytherapy treatment.