Nokea
A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)
- A. Pale-colored toes
- B. Decreased skin turgor
- C. Pain relieved by analgesia
- D. Diminished capillary refill
- E. Sensation of tingling
Correct Answer: A,D,E
Rationale: Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.
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A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?
- A. The telephone numbers of the clients
- B. The room numbers of the clients
- C. The diagnoses of the clients
- D. The names of the clients' nearest relatives
Correct Answer: A
Rationale: Using the telephone numbers of the clients is correct. According to The Joint Commission's National Patient Safety Goals, at least two unique identifiers, such as date of birth and telephone number, should be used to verify client identity before administering medications to prevent errors.
A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7-month-old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. How many should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 1.0 mL
- B. 1.2 mL
- C. 1.5 mL
- D. 2.0 mL
Correct Answer: C
Rationale: The correct dose is 1.5 mL. To calculate: (60 mg / 50 mg) * 1.25 mL = 1.5 mL. This ensures the infant receives the prescribed 60 mg of ibuprofen.
A nurse is caring for a client who has a new diagnosis of gout. Which of the following dietary recommendations should the nurse make?
- A. Limit purine-rich foods.
- B. Increase dairy intake.
- C. Avoid whole grains.
- D. Reduce fluid intake.
Correct Answer: A
Rationale: Limiting purine-rich foods, like red meat and shellfish, reduces uric acid production, helping manage gout.
A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?
- A. I will carry my baby to the nursery.
- B. I will have an identification band that matches the one my baby wears.
- C. I can remove my security band to give to a family member.
- D. I can take my baby to the lobby to visit family.
Correct Answer: B
Rationale: Having an identification band that matches the baby's band is correct. Hospital security protocols require that the mother and baby wear matching identification bands to ensure the right baby is with the right parent and prevent infant abduction or misidentification.
A nurse is reinforcing teaching with a client who is scheduled for a pulmonary function test. Which of the following instructions should the nurse include?
- A. Avoid smoking for 6 to 8 hours before the test.
- B. Take a bronchodilator before the test.
- C. Wear tight-fitting clothing.
- D. Eat a large meal before the test.
Correct Answer: A
Rationale: Avoiding smoking for 6 to 8 hours before a pulmonary function test ensures accurate measurement of lung function.