Nokea
Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?
- A. Watch for shortness of breath which may indicate a fat embolus.
- B. Begin range of motion exercises within the first 24 hours.
- C. Apply ice intermittently for the first 24 hours.
- D. After edema subsides, apply heat continuously.
Correct Answer: C
Rationale: Intermittent ice reduces swelling and pain in acute soft tissue injuries, prioritizing over other instructions.
You may also like to solve these questions
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
Exhibits
The nurse comes into the room to replace the IV bag and notices the client's extremities are jerking violently. The client is not arousable and the oxygen saturation is 59% on the monitor.
Based on the information collected, the client is likely experiencing [condition] related to [cause].
- A. Increased intracranial pressure
- B. Brain herniation
- C. Hypoxia
- D. Hypercapnia
- E. Absence seizure
- F. Decorticate posturing
- G. Tonic clonic seizure
Correct Answer: C,F
Rationale: Hypoxia from a tonic-clonic seizure causes low oxygen saturation and jerking movements, requiring urgent intervention.
While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?
- A. Stone fragments are collected when straining the client's urine.
- B. Client denies urinary frequency, urgency, or dysuria.
- C. Urine is pale pink with no observable blood clots.
- D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.
Correct Answer: A
Rationale: Collecting stone fragments directly confirms the success of lithotripsy in breaking down the stone, unlike symptom relief or lab values.
The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take?
- A. Schedule a portable chest x-ray per PRN protocol.
- B. Maintain the current IV antibiotic schedule.
- C. Obtain a specimen of the drainage for culture.
- D. Milk' the tube to remove any clots.
Correct Answer: C
Rationale: A culture of the changed drainage assesses for infection or other causes, prioritizing over imaging, antibiotics, or tube manipulation.
Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?
- A. Limit intake of chips and pretzels.
- B. Encourage mountain biking.
- C. Elevate lower extremities.
- D. Restrict fluid intake to water.
Correct Answer: C
Rationale: Elevating lower extremities reduces venous pressure and promotes blood return, directly improving circulation in chronic venous insufficiency.
A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 31
Rationale: Using the formula (250 mL x 15 gtt/mL) / 120 min = 31.25 gtt/min, rounded to 31 gtt/min.