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A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skin traction. The nurse may remove the weights from the traction device if which of the following occurs?
- A. The client develops a life-threatening situation.
- B. The client has to be repositioned in the bed.
- C. The client complains of pain.
- D. The client needs to have an x-ray of the femur performed.
Correct Answer: A
Rationale: The correct answer is A: The client develops a life-threatening situation. In this scenario, the nurse can remove the weights from the traction device to address the life-threatening situation promptly. Removing the weights in such a situation takes precedence over other concerns like repositioning, pain complaints, or even the need for an x-ray. Life-threatening situations must always be prioritized in patient care to ensure their safety and well-being. It is crucial for the nurse to act swiftly and appropriately in such emergencies to provide the necessary care and support to the client.
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A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.
- A. Prealbumin level.
- B. History of diabetes mellitus.
- C. History of hyperlipidemia.
- D. Wound infection.
- E. Decreased pedal perfusion.
- F. Fasting blood glucose.
Correct Answer: A,B,D,E,F
Rationale: The correct findings that can cause delayed wound healing are A, B, D, E, and F.
A: Prealbumin level reflects protein status, crucial for wound healing.
B: Diabetes mellitus impairs wound healing due to poor circulation and high blood sugar.
D: Wound infection delays healing by increasing inflammation and preventing tissue repair.
E: Decreased pedal perfusion reduces blood flow to the wound site, hindering healing.
F: Fasting blood glucose levels affect the body's ability to heal due to impaired immune function and reduced collagen formation.
Incorrect choices: C - Hyperlipidemia does not directly impact wound healing; G - Insufficient information provided.
A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?
- A. Unilateral joint involvement.
- B. Ulnar deviation.
- C. Decreased sedimentation rate.
- D. Fractures of the spine.
Correct Answer: B
Rationale: The correct answer is B: Ulnar deviation. In rheumatoid arthritis, ulnar deviation of the fingers is a common finding due to inflammation and destruction of the joints. This deformity leads to the fingers deviating towards the ulnar side of the hand. This is a characteristic feature seen in rheumatoid arthritis and is caused by the inflammation affecting the joints. Choices A, C, and D are incorrect. A: Unilateral joint involvement is not typical of rheumatoid arthritis, as it usually affects multiple joints symmetrically. C: Decreased sedimentation rate is not expected in rheumatoid arthritis, as it is typically associated with an elevated sedimentation rate due to inflammation. D: Fractures of the spine are not a common finding in rheumatoid arthritis, as it primarily affects the joints.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
- A. Irregular pulse.
- B. Persistent fatigue.
- C. Dependent edema.
- D. Slurred speech.
Correct Answer: D
Rationale: The correct answer is D: Slurred speech. Slurred speech can be a sign of a potential stroke, which can occur in patients with atrial fibrillation due to the risk of blood clots forming in the heart. This finding should be reported immediately to the provider for further evaluation and intervention to prevent further complications. Monitoring for slurred speech helps in early detection and prompt management of a potential stroke.
Other choices such as A: Irregular pulse, B: Persistent fatigue, and C: Dependent edema are common in patients with heart failure and atrial fibrillation but are not immediate concerns requiring urgent intervention like slurred speech indicating a potential stroke.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
- A. Friction rub.
- B. Intermittent claudication.
- C. Cardiac murmur.
- D. Dependent rubor.
Correct Answer: C
Rationale: The correct answer is C: Cardiac murmur. Endocarditis is an infection of the inner lining of the heart chambers and valves, which can lead to the development of a new murmur due to valve damage or vegetation formation. This can result in turbulent blood flow, causing the murmur. A friction rub (choice A) is more indicative of pericarditis, intermittent claudication (choice B) is associated with peripheral arterial disease, and dependent rubor (choice D) is seen in chronic arterial insufficiency. Therefore, recognizing a new cardiac murmur in a client with endocarditis is crucial as it can indicate complications such as valve dysfunction or embolic events.
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)
- A. Fat neck veins.
- B. Hypotension.
- C. Poor skin turgor.
- D. Bradycardia.
- E. Pale yellow urine.
Correct Answer: B,C
Rationale: The correct answers are B: Hypotension and C: Poor skin turgor. In a client with frequent vomiting and diarrhea, fluid loss leads to dehydration, causing hypotension and poor skin turgor. Hypotension results from decreased circulating blood volume due to fluid loss. Poor skin turgor occurs due to decreased skin elasticity from dehydration. Choices A, D, and E are incorrect. Fat neck veins are not typical findings in dehydration. Bradycardia is not expected in dehydration; tachycardia is more common due to compensatory mechanisms to maintain cardiac output. Pale yellow urine is indicative of concentrated urine, not a typical finding in dehydration.