Nokea
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- B. Clamp the catheter tubing distal to the sampling port for 15 min.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen
- D. Document in the client's electronic medical record that the specimen was sent to the laboratory.
- E. Empty the urine into a sterile container labeled with the client identifiers
Correct Answer: B,A,C,E,D
Rationale: Sequence: Clamp tubing (B) to collect urine, wipe port (A), aspirate with syringe (C), transfer to container (E), and document (D) for a sterile specimen.
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A nurse is reinforcing dietary teaching with an older adult client who has an increased LDL level. Which of the following foods should the nurse encourage the client to limit?
- A. Canola oil
- B. Swiss cheese
- C. Avocados
- D. Walnuts
- E. Olive oil
- F. Fatty fish
- G. Whole grains
Correct Answer: B
Rationale: Swiss cheese is high in saturated fat, raising LDL; canola oil, avocados, and walnuts are heart-healthy.
A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include?
- A. Obtain the client's rectal temperature every 4 hr.
- B. Prohibit fresh flowers in the client's room.
- C. Encourage the client to eat a low-protein diet.
- D. Initiate airborne precautions for the client.
- E. Monitor daily CBC.
- F. Limit visitors.
- G. Use strict hand hygiene.
Correct Answer: B
Rationale: Fresh flowers can harbor bacteria, increasing infection risk in neutropenia; rectal temps risk injury, and airborne isn't needed.
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.
VITAL SIGNS
Day 1:
TEMPERATURE 36° C (96.8° F)
BLOOD PRESSURE 140/80 mm Hg
HEART RATE 98/min
RESPIRATORY RATE 24/min
OXYGEN SATURATION 97% on room air
Day 2, 0800:
TEMPERATURE 37° C (98.6° F)
BLOOD PRESSURE 122/60 mm Hg
HEART RATE 85/min
RESPIRATORY RATE 18/min
OXYGEN SATURATION 98% on room air
Day 2, 1600:
Findings
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
Acute compartment syndrome
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
Infection
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
Fat embolism syndrome
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia. Which finding is consistent with acute compartment syndrome?
- A. Dyspnea
- B. Tingling sensation to right foot
- C. Increased pain at incision site
- D. Swelling at incision site
Correct Answer: A, C
Rationale: Acute compartment syndrome post-ORIF arises from pressure buildup in muscle compartments, impairing perfusion. Increased pain at the incision site severe, unrelieved by analgesics, and disproportionate to the procedure is a hallmark, reflecting nerve and tissue ischemia. Dyspnea suggests fat embolism syndrome, a separate complication from marrow release, not compartment pressure. Tingling indicates nerve compression, a later sign, but pain precedes it in the 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia). Swelling occurs, but pain's intensity and persistence distinguish compartment syndrome from normal postoperative edema. Early recognition of escalating pain prompts fasciotomy, preventing necrosis, making it the most consistent finding per orthopedic emergency protocols.
An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result?
- A. A client whose injection site is scabbed
- B. A client whose injection site is firm and measures 3 mm (0.1 in)
- C. A client whose injection site has an elevated area measuring 15 mm (0.6 in)
- D. A client whose injection site is ecchymotic
Correct Answer: C
Rationale: An induration of 15 mm after 48 hours indicates a positive TB skin test, suggesting exposure or infection. Smaller indurations, scabbing, or bruising do not meet the criteria for a positive result.