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A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
- A. Apply medicated powder under the vest to reduce itching.
- B. Move the client up and down in bed by holding onto the halo traction device.
- C. Ensure that there is space for one finger to fit between the vest and the client's skin.
- D. Locate or tighten the screws on the device as needed for the client's comfort.
Correct Answer: C
Rationale: The correct answer is C: Ensure that there is space for one finger to fit between the vest and the client's skin. This is important to prevent pressure ulcers and skin breakdown. Tight vest can lead to skin irritation. Applying medicated powder (A) may further irritate the skin. Moving the client by holding the halo traction device (B) can lead to dislodgement or injury. Locating or tightening screws (D) should only be done by healthcare providers to prevent complications.
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A nurse is caring for a client who is postoperative following a below-the-knee amputation. Which of the following statements made by the client indicates acceptance of their altered body image?
- A. I would like to meet with another client who has had an amputation.
- B. I would rather not look at my stump during a dressing change.
- C. I am glad that I no longer have to deal with my infected leg.
- D. I understand that I will be unable to return to my job.
Correct Answer: A
Rationale: The correct answer is A: "I would like to meet with another client who has had an amputation." This statement indicates acceptance of the altered body image as the client is actively seeking connection with others who have gone through a similar experience. By expressing a desire to meet someone with a similar amputation, the client is acknowledging and normalizing their own situation, showing acceptance and readiness to engage in discussions about their body image.
Summary of why other choices are incorrect:
B: "I would rather not look at my stump during a dressing change." - This statement suggests avoidance and discomfort with the amputation, indicating a lack of acceptance.
C: "I am glad that I no longer have to deal with my infected leg." - While this statement may indicate relief from a health issue, it does not necessarily demonstrate acceptance of the altered body image.
D: "I understand that I will be unable to return to my job." - This statement reflects resignation to a limitation but does not directly address body
A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?
- A. Encourage frequent visits from friends.
- B. Apply restraints to the upper extremities.
- C. Play soft, soothing music.
- D. Keep the over-the-bed light on.
Correct Answer: C
Rationale: The correct answer is C: Play soft, soothing music. This is beneficial for the older adult with dementia post-surgery as music has been shown to reduce anxiety, improve mood, and promote relaxation. It can also help in reducing agitation and promoting better sleep. Encouraging frequent visits from friends (A) may overwhelm the client. Applying restraints to the upper extremities (B) can lead to increased agitation and discomfort. Keeping the over-the-bed light on (D) may disrupt sleep patterns and worsen confusion.
A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
- A. Make sure the client's room has positive pressure airflow.
- B. Make sure dietary plates and utensils are disposable.
- C. Wear an N95 respirator when providing direct client care.
- D. Monitor the client's temperature once every 6 hours.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Positive pressure airflow in the client's room helps prevent airborne contaminants from entering, reducing the risk of infection.
2. This intervention creates a controlled environment suitable for clients with compromised immune systems.
3. The positive pressure airflow system pushes air out of the room, minimizing the risk of external pathogens entering.
4. This measure is crucial in protective isolation to protect the client from infections during the vulnerable post-transplant period.
Summary:
- Choice B is not directly related to infection prevention in protective isolation.
- Choice C is important for respiratory infections but is not a primary intervention for protective isolation.
- Choice D is relevant but does not directly address infection prevention measures in protective isolation.
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?
- A. Oxygen saturation
- B. Warm extremities
- C. Temperature
- D. Level of pain
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation. Ensuring adequate oxygen saturation is the nurse's priority because the client received moderate sedation, which can depress the respiratory drive. Monitoring oxygen saturation helps to detect any signs of respiratory distress early on. Warm extremities (B) and temperature (C) are important but not the priority in this situation. Pain management (D) is important but not as critical as ensuring adequate oxygenation.
A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?
- A. Obtain an ECG.
- B. Administer an opioid pain medication.
- C. Infuse IV fluids to maintain urine output at 75 mL/hr.
- D. Change dressings over the entrance and exit wounds.
Correct Answer: A
Rationale: The correct answer is A: Obtain an ECG. The first step in managing a client with an electrical shock injury is to assess for any cardiac complications, as electrical shock can cause arrhythmias. Obtaining an ECG will help the nurse identify any abnormal heart rhythms and determine the need for immediate intervention. Administering opioid pain medication (B) is not a priority as assessing the cardiac status takes precedence. Infusing IV fluids (C) is important but not the first priority. Changing dressings (D) can wait until the client's immediate medical needs are addressed.