Nokea
A nurse working in an orthopedic unit is caring for 4 clients. Which of the
following clients should the nurse identify as being at highest risk for skin
breakdown?
- A. An adolescent who has a patella fracture and is in an immobilizer
- B. A young adult who has a femur fracture and is going to surgery in two hours
- C. A middle-aged adult who has fractured his radius and has a cast
- D. An older adult who has a hip fracture and is immobile
Correct Answer: D
Rationale:
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A client has an abdominal incision. The surgical wound was closed with 10
sutures. This surgical wound is healing by what process?
- A. Primary intention
- B. Binary intention
- C. Secondary intention
- D. None of the Above
Correct Answer: A
Rationale:
The nurse is caring for a 65-year-old client and notes a temperature of 101°F. How does the nurse interpret this finding?
- A. Hyperthermia
- B. A cold environment
- C. Normal
- D. Hypothermia
Correct Answer: A
Rationale: A temperature of 101°F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101°F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.
The nurse is caring for 4 clients. What client should the nurse see first?
- A. A client with multiple children visiting
- B. A client with lupus asking for dinner
- C. A client on Methotrexate with a fever
- D. A client with chronic rheumatic pain
Correct Answer: C
Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.
What is the nurse's priority action for a client with compromised immunity?
- A. Wash hands before entering the client's room
- B. Take the client's vital signs every 4 hours
- C. Determine whether it is temporary or permanent
- D. Teach the family members to receive the flu shot annually
Correct Answer: A
Rationale:
A client is diagnosed with systemic sclerosis (scleroderma). What symptoms is
the first to occur?
- A. Tachycardia
- B. Raynaud's phenomenon
- C. Intense wrinkle
- D. Joint pain
Correct Answer: B
Rationale: