Nokea
A nurse is caring for a client who is in skin traction. Which of the following actions should the nurse take?
- A. Ensure the weights hang freely from the bed.
- B. Inspect the client's skin every 12 hours for signs of breakdown.
- C. Loosen the ropes of the pulleys when repositioning the client in bed.
- D. Maintain 6.8 kg (15 lb) of weight for the skin traction.
Correct Answer: A
Rationale: Ensuring weights hang freely (A) maintains proper traction alignment, critical for effectiveness.
You may also like to solve these questions
A nurse is caring for a client who has dysphagia following a stroke. The nurse should recommend a referral to which of the following members of the interdisciplinary team?
- A. Occupational therapist
- B. Speech therapist
- C. Respiratory therapist
- D. Physical therapist
Correct Answer: B
Rationale: A speech therapist (B) specializes in managing dysphagia, aiding swallowing post-stroke.
An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hours ago. Which of the following clients should the nurse identify as having a positive test result?
- A. A client whose injection site is ecchymotic
- B. A client whose injection site is scabbed
- C. A client whose injection site has an elevated area measuring 15 mm (0.6 in)
- D. A client whose injection site is firm and measures 3 mm (0.1 in)
Correct Answer: C
Rationale: An elevated area of 15 mm (C) indicates a positive TB test, suggesting possible infection.
A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
- A. Initiate contact precautions for the client.
- B. Monitor the client's temperature every 6 hours.
- C. Measure the client's intake and output every 8 hours.
- D. Dim the lighting in the client's room.
Correct Answer: D
Rationale: Dimming lights (D) alleviates photophobia, a common symptom in viral meningitis, improving client comfort.
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?
- A. Activate the fire alarm system.
- B. Use a fire extinguisher at the source of the smoke.
- C. Close the doors to the room and to the bathroom.
- D. Assist the client to a nearby common area.
Correct Answer: D
Rationale: Assisting the client to safety (D) is the first action in a fire situation, prioritizing client well-being.
A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?
- A. Withhold the medication if the systolic blood pressure is less than 90 mm Hg.
- B. Administer the medication with an antacid.
- C. Instruct the client to expect increased hair growth.
- D. Request a dosage increase if the apical heart rate is less than 50/min.
Correct Answer: A
Rationale: Withholding propranolol if systolic BP is below 90 mm Hg (A) prevents hypotension, a key safety action.