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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. Right foot pale with sluggish capillary refill.
- B. Circumferential edema of right foot.
- C. Reports throbbing right leg pain.
- D. Increased temperature to lower extremity.
Correct Answer: A
Rationale: A pale right foot with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, requiring immediate intervention to prevent tissue damage.
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The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Have the antifungal creams been effective?
- B. Do your family members share combs and brushes?
- C. Do you have any dry patches on your feet and hands?
- D. Has everyone at home already had varicella?
Correct Answer: D
Rationale: Asking whether everyone at home has had varicella is important, as herpes zoster can transmit the varicella-zoster virus to non-immune individuals, causing chickenpox.
History and Physical Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Orders
Administer albuterol 2.5 mg/ipratropium bromide 0.5 mg in 3 mL solution via nebulizer four times a day and PRN.
Administer prednisone 60 mg PO
Administer oxygen to keep oxygen saturation greater than 94%, titrate as needed.
The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful.
- A. Decrease in heart rate from 112 to 105 beats per minute.
- B. Client able to speak in full sentences without pausing.
- C. Clear lung sounds.
- D. Reduction in respiratory rate to 16 breaths per minute.
- E. Client reports breathing is eased.
- F. Blood pressure within normal limits.
Correct Answer: A,B,C,D,E,F
Rationale: The assessment data showing decreased heart rate, ability to speak in full sentences, clear lung sounds, reduced respiratory rate, eased breathing, and stable blood pressure all indicate successful interventions for the asthma attack.
A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with 0.9% sodium chloride is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Discontinue infusing solution.
- B. Irrigate the catheter manually.
- C. Monitor catheter drainage.
- D. Decrease the flow rate.
Correct Answer: C
Rationale: Monitoring catheter drainage allows the nurse to assess the effectiveness of bladder irrigation and the presence of clot formation, ensuring adequate drainage.
The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care?
- A. Ensure oral suction is available.
- B. Provide frequent mouth care.
- C. Keep the room at a comfortable temperature.
- D. Maintain the client in a semi-Fowler's position.
Correct Answer: A
Rationale: Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.
The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
- A. Have the client sign the surgical and transfusion permits.
- B. Notify the healthcare provider of the client's medication history.
- C. Ensure that the potential for bleeding is explained to the client.
- D. Observe the heparin injections sites for signs of bruising.
Correct Answer: B
Rationale: Notifying the healthcare provider of the client's heparin use is crucial to ensure appropriate perioperative management and prevent excessive bleeding during surgery.