Nokea
A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should:
- A. Place a pillow under the child's buttocks to provide support.
- B. Remove the weight from the left leg.
- C. Assess the feet for signs of neurovascular impairment.
- D. Reposition the pulleys so the traction is looser.
Correct Answer: C
Rationale: Assessing for neurovascular impairment is critical, as pain could indicate compromised circulation or nerve function.
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The nurse mentions that a group meeting for mothers of mentally retarded children is to be held soon. 'Not retarded!' the child's mother angrily blazes, 'Exceptional.' When responding to this outburst, which of the following replies by the nurse would be most appropriate?
- A. Retarded' is the commonly used and accepted term.'
- B. I'm sorry if I offended you by my thoughtless remark.'
- C. No matter what it's called, the condition is still the same, isn't it?'
- D. I'd like to hear more of your thoughts and feelings on that.'
Correct Answer: D
Rationale: Inviting the mother to share her feelings promotes therapeutic communication and addresses her emotional response sensitively.
When developing the plan of care for a child with cystic fibrosis (CF) who is scheduled to receive postural drainage, the nurse should anticipate performing postural drainage at which of the following times?
- A. After meals.
- B. Before meals.
- C. After rest periods.
- D. Before inhalation treatments.
Correct Answer: B
Rationale: Postural drainage should be performed before meals to avoid discomfort and reduce the risk of vomiting, as it involves positioning to facilitate mucus clearance.
Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine?
- A. What they know about the legal implications of drinking.
- B. The type of alcohol they usually drink.
- C. The reasons they choose to use alcohol.
- D. When and with whom they use alcohol.
Correct Answer: C
Rationale: Understanding the reasons for alcohol use helps address underlying issues and tailor interventions.
A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL. Using the 15-15 rule, the nurse should:
- A. Give 15 mL of juice and give another 15mL in 15 minutes.
- B. Give 15 g of carbohydrate and retest the blood sugar in 15 minutes.
- C. Give 15 g of carbohydrate and 15 g of protein.
- D. Give 15 oz of juice and retest in 15 minutes.
Correct Answer: B
Rationale: The 15-15 rule involves giving 15 g of fast-acting carbohydrate (e.g., 4 oz juice) and retesting after 15 minutes to correct hypoglycemia. Protein is not immediate, and incorrect volumes (15 mL or 15 oz) are ineffective.
A 10-year-old has 5 lb of Buck's extension traction on his left leg. The nurse should assess the child for which of the following? Select all that apply.
- A. Dryness of the skin, by removing the foam wraps and boot.
- B. Alignment of the shoulder, hips, and knees.
- C. Frayed rope near pulleys.
- D. Correct amount of traction weight on fracture.
- E. Pressure on the coccyx.
Correct Answer: B,C,D,E
Rationale: The nurse should check alignment, rope condition, weight accuracy, and pressure points to ensure effective and safe traction.