Nokea
A nurse is reinforcing teaching about meal planning with a client who has hypertension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can season food with ketchup.
- B. I can season food with vinegar.
- C. I can have a bologna sandwich
- D. I can have canned soup.
Correct Answer: B
Rationale: Vinegar is low in sodium, unlike ketchup, bologna, or canned soup, aligning with hypertension dietary teaching.
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A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
The nurse is collecting data on the client. Which of the following findings require follow up?
- A. Findings of right lower extremity assessment
- B. Pain level
- C. Level of consciousness
- D. Oxygen saturation
- E. Right pedal pulses
- F. Temperature
- G. X-ray results
Correct Answer: A,B,E
Rationale: Right lower extremity findings (swelling, open wound), severe pain, and weak right pedal pulses indicate potential fracture or vascular compromise needing follow-up.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced.
The nurse is assisting in the plan of care for the client who has compartment syndrome. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
- A. Open the splint
- B. Place the client on NPO status
- C. Place the client's right leg in a dependent position
- D. Obtain a urinalysis
Correct Answer: A (anticipated), B (anticipated), C (contraindicated), D (anticipated)
Rationale: Opening the splint relieves pressure in compartment syndrome; NPO status prepares for surgery; a dependent position worsens swelling; urinalysis assesses for rhabdomyolysis.
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
- D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
Correct Answer: C
Rationale: A platelet count of 60,000/mm3 is significantly below the normal range, increasing the risk of bleeding during a liver biopsy, and should be reported to the provider.
A nurse is reinforcing teaching with the family of a client who has methicillin-resistant Staphylococcus aureus (MRSA) of a leg wound and is on contact precautions. Which of the following statements by a family member indicates an understanding of the teaching?
- A. There is no cure for MRSA.
- B. We will need to wear masks when we are in the hospital room.
- C. MRSA only occurs in health care facilities.
- D. We should remove gloves before leaving the hospital room.
Correct Answer: D
Rationale: Removing gloves before leaving prevents the spread of MRSA, consistent with contact precautions.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced.
A nurse is assisting in the care of a client who The first action the nurse should take is to followed by. is postoperative following an open reduction internal fixation of the right tibia. Complete the following sentence by using the lists of options. The first action the nurse should take is to..... followed by.....
- A. Assess neurovascular status.
- B. Elevate the leg.
- C. Administer prescribed pain medication
- D. Monitor vital signs
- E. Apply a sterile dressing to the wound
- F. Notify the provider
Correct Answer: A,F
Rationale: Assessing neurovascular status first identifies complications like compartment syndrome, followed by notifying the provider for urgent intervention.