Nokea
A nurse is reinforcing teaching with a 30-year-old client who is concerned about cervical cancer. Which of the following statements should the nurse make?
- A. Cervical cancer screenings should begin at age 40
- B. Plan to continue cervical cancer screenings for the rest of your life.
- C. You should get a Papanicolaou (Pap) test and human papillomavirus test every 5 years.
- D. If you are immunized against human papillomavirus, you don't need cervical cancer screenings.
Correct Answer: C
Rationale: For a 30-year-old, Pap and HPV testing every 5 years is recommended per current guidelines, making this the correct statement.
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A nurse is assisting in the care of the client who is postoperative following a fasciotomy.
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 right leg upon falling. Right leg was immobilized at the scene and 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.
Day 3, 2300:
Client is alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Right leg with splint in place. Incisional dressing dry and intact. Wound drain to negative-pressure vacuum, draining small amounts of serosanguinous fluid. Bilateral pedal pulses 3+. feet warm with intact movement and sensation. Client reports pain as a 4 on a scale of 0 to 10.
The nurse is reviewing the client's electronic medical record (EMR). Select statements in the EMR that indicate the client's condition is improving since implementing interventions.
- A. Temperature 37.8°C (100°F)
- B. Client is alert and oriented to person, place, and time
- C. Bilateral breath sounds clear and present throughout
- D. Feet warm with intact movement and sensation
- E. Heart rate 98/min
- F. Bilateral pedal pulses 3+
- G. Respiratory rate 20/min
Correct Answer: B,C,D
Rationale: Alertness, clear breath sounds, and warm feet with intact sensation indicate recovery from the initial injury and fasciotomy.
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.
A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?
- A. Insert an indwelling urinary catheter and record the client's output.
- B. Set up the equipment using clean technique.
- C. Prepare the client for a chest x-ray following the procedure.
- D. Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.
Correct Answer: C
Rationale: A chest x-ray post-thoracentesis confirms lung re-expansion and checks for complications like pneumothorax.
A nurse is reinforcing teaching with a client who is to undergo a bone marrow aspiration. Which of the following statements should the nurse include in the teaching?
- A. You will need to fast for 2 hours before the procedure.
- B. You will have the bone marrow taken from your femur.
- C. You will not receive a local anesthetic agent for this procedure.
- D. I will hold pressure on the site after the procedure.
Correct Answer: D
Rationale: Holding pressure on the site post-procedure prevents bleeding, a standard part of bone marrow aspiration care.
A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?
- A. Perform suctioning.
- B. Instill saline into the tubing.
- C. Increase the humidification.
- D. Check the cuff pressure.
Correct Answer: A
Rationale: Restlessness and crackles in the lungs suggest secretions in the airway, and suctioning is the appropriate intervention to clear them in a client with a tracheostomy.