Nokea
After assessing the client's cast, what action should the nurse take next?
- A. Document the finding in the medical record.
- B. Call the physician and report the finding.
- C. Check the nurse, then record the nurse.
- D. Apply an ice bag over the drainage area.
Correct Answer: B
Rationale: Bloody drainage seeping through a cast suggests potential complications like infection or tissue damage, requiring immediate physician notification for evaluation. Documentation and ice application are secondary, and the third option is unclear.
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During a physical exam on the 18-month-old, the nurse observes genu varum. What should the nurse do?
- A. Document the finding as normal
- B. Report this finding to the HCP
- C. Teach the parents about rickets
- D. Prepare the parent about using braces
Correct Answer: A
Rationale: Genu varum (bowlegs) is a normal finding in children up to 2 years old and should be documented as normal.
The nurse would be correct to request a consultation with a dietitian if the client chooses a meal that includes which food?
- A. Nuts
- B. Milk
- C. Eggs
- D. Liver
Correct Answer: D
Rationale: Liver is high in purines, which increase uric acid levels, worsening gout. Nuts, milk, and eggs are low-purine foods, suitable for a gout diet, necessitating a dietitian consultation for education.
The day after an amputation, the client begins to hemorrhage from his stump. What action should the nurse take first?
- A. Apply a pressure dressing to the stump
- B. Place a tourniquet above the stump
- C. Notify the physician
- D. Apply an ice pack to the stump
Correct Answer: A
Rationale: Applying a pressure dressing is the first action to control hemorrhage, followed by notifying the physician.
Which illustration demonstrates abduction for a 10-year-old who had an SCI?
- A. ROM-1.png
- B. ROM-2.png
- C. ROM-3.png
- D. ROM-4.png
Correct Answer: A
Rationale: Abduction involves moving a limb away from the body's midline, as shown in the correct illustration.
What should the nurse admitting the child with autism do about the room assignment?
- A. Request that the child be transferred to a private room.
- B. Request that the child be transferred to a double room.
- C. Admit the child to the room that has been preassigned.
- D. Request that the child be assigned to an isolation room.
Correct Answer: A
Rationale: A private room is preferred for a child with autism to minimize sensory overload and ensure a calm environment.