Nokea
A five-year-old girl after the application of a cast to the left arm.
After the cast is applied, the nurse should
- A. petal the edges of the cast to prevent irritation.
- B. elevate the client's left arm on two pillows.
- C. apply cool, humidified air to dry the cast.
- D. ask the client to move her fingers to maintain mobility.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) done when cast is completely dry, prevents crumbling of plaster into cast (2) correct-minimizes swelling, elevated for first 24-48 hours, protects from pressure and flattening of cast (3) would delay drying of cast (4) maintaining mobility of fingers not most important after application of cast
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The nurse is teaching a client with a new diagnosis of heart failure about carvedilol (Coreg). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report dizziness or lightheadedness.
- C. Stop the medication if symptoms improve.
- D. Avoid checking pulse rate.
Correct Answer: B
Rationale: Dizziness or lightheadedness may indicate hypotension, a carvedilol side effect, requiring reporting. Options A, C, and D are incorrect.
A 2-month-old boy with a temperature of $102°F (39°C) is brought to the emergency department by his mother.
- A. What should the nurse’s response be based on regarding a fever in a 2-month-old one week after a DPT immunization?
- B. If a fever does occur in a child after a DPT, it usually occurs within the first 2 hours.
- C. An elevated temperature is very rarely seen in a child after a DPT immunization.
- D. If there is a fever after a DPT, it is usually low-grade and appears within the first 48 hours.
- E. The child’s high fever is a direct response to the DPT immunization and should be treated.
Correct Answer: C
Rationale: A low-grade fever within 24-48 hours is a common response to DPT immunization. A high fever (102°F) one week later is unlikely related to the immunization and should be reported to a physician for evaluation, possibly indicating another cause.
The nurse is caring for a client with a history of chronic lymphocytic leukemia.
- A. Which symptom should the nurse report immediately for a client with chronic lymphocytic leukemia?
- B. Fatigue and weakness.
- C. Enlarged, painless lymph nodes.
- D. Fever and night sweats.
- E. A hemoglobin of 9.0 g/dL.
Correct Answer: C
Rationale: Fever and night sweats may indicate infection or disease progression in chronic lymphocytic leukemia, requiring immediate evaluation. Fatigue, lymph node enlargement, and low hemoglobin are expected.
A client has received an IV antibiotic every eight hours for four days.
- A. Which finding would cause the nurse to be concerned about postinfusion phlebitis in a client receiving IV antibiotics?
- B. Tenderness at the IV site.
- C. Increased swelling at the insertion site.
- D. Reddened area or red streaks at the site.
- E. Leaking of fluid around the IV catheter.
Correct Answer: C
Rationale: Postinfusion phlebitis is characterized by inflammation, with reddened areas or streaks along the vein. Tenderness is common, swelling suggests infiltration, and leaking indicates poor catheter placement, but redness is the hallmark of phlebitis.
A 68-year-old client has an order for hydrochlorothiazide (Hydrodiuril) 50 mg qd. The nurse knows that teaching has been successful if the client makes which of the following statements?
- A. I should not operate heavy machinery.
- B. I should drink only five glasses of liquid per day.
- C. This medication will cause my urine to turn orange.
- D. I should eat dried apricots each day.
Correct Answer: D
Rationale: Hydrochlorothiazide causes potassium loss; eating potassium-rich apricots indicates understanding. Options A, B, and C are incorrect.