Nokea
A nurse is collecting data from a client who had a long arm cast applied 2 hr. ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately?
- A. The client's fingers are cool to the touch.
- B. The client reports severe itching under the cast.
- C. The client's capillary refill is 3 seconds.
- D. The client reports increased pain at the area of the fracture.
Correct Answer: A
Rationale: Cool fingers suggest impaired circulation, a potential emergency post-cast application requiring immediate reporting. Itching and pain are common, and 3-second refill is borderline normal.
You may also like to solve these questions
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?
- A. Administer a prescribed oral dose of trazodone to the client.
- B. Encourage the client to ambulate with a staff member.
- C. Isolate the client in their room.
- D. Apply bilateral wrist restraints to the client.
Correct Answer: A
Rationale: Prescribed trazodone addresses agitation pharmacologically. Other options are less effective or inappropriate for immediate management of agitation in Alzheimer's.
A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?
- A. History of generalized anxiety disorder
- B. Recent exposure to tuberculosis
- C. Reports periodic migraine headaches
- D. Experiences nocturia
Correct Answer: B
Rationale: Recent tuberculosis exposure is a public health priority it's contagious via airborne droplets, risking spread in a semi-private room. Immediate isolation and testing (e.g., PPD, chest X-ray) protect the client, roommate, and staff, per CDC guidelines. Anxiety disorder affects mental health but isn't acutely transmissible or life-threatening here. Migraines cause discomfort, not immediate danger, manageable with later intervention. Nocturia disrupts sleep and may signal underlying issues, but it's less urgent than infection control. TB exposure triggers rapid response respiratory isolation, contact tracing due to its morbidity (e.g., pulmonary damage) and outbreak potential, making it the top priority to address on admission.
A nurse administered a dose of penicillin to a client 30 min ago. The client reports she has hives and is itching. Which of the following statements by the nurse is the highest priority?
- A. I'm going to take your heart rate.
- B. I need to give you diphenhydramine.
- C. Are you having difficulty breathing?
- D. Do you have any allergies to medications?
Correct Answer: C
Rationale: Asking about difficulty breathing is the priority as it assesses for anaphylaxis, a life-threatening allergic reaction to penicillin, requiring immediate intervention.
A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee stiffness upon ambulation. Which of the following interventions should the nurse include in the plan of care?
- A. Apply moist heat prior to ambulation.
- B. Delay ambulation until the next day
- C. Use a continuous passive motion machine
- D. Rest in a soft chair
- E. Apply cold packs.
- F. Increase weight-bearing exercise.
- G. Avoid all movement.
Correct Answer: A
Rationale: Moist heat reduces stiffness and improves mobility in osteoarthritis.
A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
- A. You will not become fatigued when you use assistive devices.
- B. Plan to hire a home care aid to perform all of your ADLs.
- C. Install grab bars in your shower to assist with your balance.
- D. Place a towel in the shower to prevent slipping
Correct Answer: C
Rationale: Grab bars enhance safety and independence in the shower post-CVA. Fatigue is possible, full assistance isn't always needed, and a towel could be a slip hazard.