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After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Increased temperature to lower extremity.
- B. Circumferential edema of right foot.
- C. Right foot pale with sluggish capillary refill.
- D. Reports throbbing right leg pain.
Correct Answer: C
Rationale: Pale foot with sluggish capillary refill indicates compromised circulation, risking tissue ischemia requiring urgent intervention.
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The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Increase Intake of potassium rich foods such as bananas or cantaloupe.
- B. Restrict protein intake by limiting meats and other high protein foods.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of high fiber foods, such as bran cereal.
Correct Answer: B
Rationale: Restricting protein reduces kidney workload and proteinuria, preserving function in glomerulonephritis.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Do your family members share combs and brushes?
- B. Do you have any dry patches on your feet and hands?
- C. Has everyone at home already had varicella?
- D. Have the antifungal creams been effective?
Correct Answer: C
Rationale: Asking about varicella history assesses the risk of chickenpox transmission to susceptible household members from herpes zoster.
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Remain upright following meals.
- B. Avoid wearing tight fitting clothes.
- C. Minimize intake of spicy foods.
- D. Begin a smoking cessation program.
Correct Answer: A
Rationale: Remaining upright prevents gastric reflux by aiding stomach emptying, directly addressing GERD symptoms.
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
- A. Bring additional sterile dressing supplies to the room.
- B. Auscultate the abdomen for bowel sound activity.
- C. Obtain a sample of the drainage to send to the laboratory.
- D. Prepare the client to return to the operating room.
Correct Answer: D
Rationale: Evisceration is a surgical emergency requiring immediate operative repair to prevent complications.
A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
- A. Palpate the right flank for tenderness.
- B. Evaluate the urine for a strong odor.
- C. Test the urine for the presence of hematuria.
- D. Measure the temperature and pulse rate.
Correct Answer: D
Rationale: Measuring temperature and pulse assesses for systemic infection, such as pyelonephritis, which is urgent given the symptoms.