Nokea
A patient is on bedrest 24 hours after a hip fracture. Which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome?
- A. Performing passive, light range-of-motion exercises on the hip as tolerated.
- B. Assess the patient's mental status for drowsiness or sleepiness.
- C. Assess the pedal pulse and capillary refill in the toes.
- D. Administer a stool softener as ordered.
Correct Answer: B
Rationale: In detecting or preventing Fat Embolism Syndrome (FES), assessing the patient's mental status for drowsiness or sleepiness is crucial. Decreased level of consciousness is an early sign of FES due to decreased oxygen levels. Performing passive, light range-of-motion exercises on the hip may not directly relate to FES. Assessing pedal pulse and capillary refill in the toes is essential for assessing circulation but not specific to detecting FES. Administering a stool softener, while important for preventing constipation in immobilized patients, is not directly related to detecting or preventing FES.
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The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?
- A. Irritability
- B. Slight edema at the injection site
- C. Local tenderness
- D. Temperature of 102.5?F
Correct Answer: D
Rationale: A temperature of 102.5°F or higher following immunization is considered an adverse reaction and should be reported immediately. This could indicate a more serious systemic response to the vaccine. Irritability, slight edema at the injection site, and local tenderness are common, mild side effects of routine immunizations and do not typically require immediate reporting. Other reactions that should be reported immediately include excessive crying for more than 3 hours, seizure activity, and the presence of tender, swollen, or reddened areas at the injection site.
A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse's best explanation of these findings?
- A. These side effects are common and should subside in a few days.
- B. The client is probably having an allergic reaction and should discontinue the drug.
- C. Taking the lithium on an empty stomach should decrease these symptoms.
- D. Decreasing dietary intake of sodium and fluids should minimize the side effects.
Correct Answer: A
Rationale: The correct answer is, 'These side effects are common and should subside in a few days.' Nausea, metallic taste, and fine hand tremors are common side effects of lithium carbonate (Lithane) and typically diminish within a few days as the body adjusts to the medication. Option B is incorrect because these symptoms are not indicative of an allergic reaction. Option C is incorrect as taking lithium on an empty stomach does not directly address or decrease these specific side effects. Option D is also incorrect as reducing sodium and fluid intake is not the recommended approach to managing these particular side effects of lithium.
A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition?
- A. Cracks at the corners of the mouth
- B. Altered mental status
- C. Bleeding gums and loose teeth
- D. Anorexia and diarrhea
Correct Answer: C
Rationale: A client with a severe vitamin C deficiency has a condition called scurvy. Scurvy is characterized by symptoms such as bleeding gums, loose teeth, poor wound healing, and easy bruising. The correct answer is 'Bleeding gums and loose teeth' because these are classic signs of scurvy due to vitamin C deficiency. Choice A ('Cracks at the corners of the mouth') is more indicative of a deficiency in B vitamins, specifically riboflavin. Choice B ('Altered mental status') is not typically associated with vitamin C deficiency but can occur with other conditions like vitamin B12 deficiency. Choice D ('Anorexia and diarrhea') are not common symptoms of vitamin C deficiency, as they are more commonly associated with other gastrointestinal issues or deficiencies in different nutrients.
Application - The nurse is caring for a patient who has the following labs: Creatinine 2.5mg/dL, WBC 11,000 cells/mL, and Hemoglobin of 12 g/dL. Based on this information, which of these orders would the nurse question?
- A. Administer 30 Units of Lantus Daily
- B. CT of the spine with contrast
- C. X-ray of the abdomen and chest
- D. Administer heparin subcutaneously 5,000 Units every 12 hours
Correct Answer: B
Rationale: The correct answer is to question the order for a CT of the spine with contrast. The patient's elevated creatinine level of 2.5mg/dL indicates impaired kidney function. Contrast agents are nephrotoxic and can further compromise kidney function in patients with existing nephropathy. Therefore, it is crucial to avoid contrast-enhanced imaging studies in patients with impaired renal function.
Choice A: Administering 30 Units of Lantus Daily is not contraindicated based on the provided lab values.
Choice C: Ordering an X-ray of the abdomen and chest is not contraindicated based on the provided lab values.
Choice D: Administering heparin subcutaneously at 5,000 Units every 12 hours is not contraindicated based on the provided lab values.
When asked to describe in layman's terms an overview of the condition called osteomyelitis, what would be the nurse's best response?
- A. Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age-related.
- B. Osteomyelitis is caused by not having enough Vitamin D, which in turn causes your bones to be softer and demineralized.
- C. Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body.
- D. This is a question that should be directed to your healthcare provider.
Correct Answer: C
Rationale: Osteomyelitis is an infection in the bone that can be caused by bacteria reaching the bone either from outside the body (such as through an open fracture) or inside the body (such as through the bloodstream). This response provides a concise and accurate explanation of osteomyelitis, making it the best choice. Choices A and B provide inaccurate information about the condition, attributing it to age-related bone breakdown and Vitamin D deficiency, which are not correct causes of osteomyelitis. Choice D deflects the question instead of providing the patient with a clear explanation, making it an inappropriate response.