Nokea
An elderly client with a fractured hip is placed in Buck's traction. The primary purpose for Buck's traction for this client is:
- A. To decrease muscle spasms
- B. To prevent the need for surgery
- C. To alleviate the pain associated with the fracture
- D. To prevent bleeding associated with hip fractures
Correct Answer: A
Rationale: Buck's traction immobilizes the hip to reduce muscle spasms, which can worsen pain and misalignment. It does not prevent surgery or bleeding and is not primarily for pain relief.
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A client is scheduled for a cardiac catheterization at 8 AM. The client's laboratory work was completed five days ago. The results were: K⺠3.0 mEq/L, Na⺠148 mEq/L, glucose 178 mg/dL. He complains of muscle weakness and cramps.
Which of the following nursing actions is BEST?
- A. Administer the 7 AM dose of spironolactone (Aldactone).
- B. Encourage eating bananas for breakfast.
- C. Obtain stat K⺠level.
- D. Call for twelve-lead EKG.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) Aldactone is potassium-sparing diuretic and is an oral medication, patient is NPO for procedure (2) is not feasible prior to the cardiac cath because the client is NPO (3) correct-signs and symptoms are indicative of hypokalemia; stat serum K⺠level is needed to confirm the K⺠level prior to going for cardiac catheterization (4) is unnecessary at this time
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Respiratory rate of 24 breaths/min.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
A ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister.
The nurse should
- A. document the findings in the chart.
- B. call the physician immediately to report the injury.
- C. teach the client that oil holds germs and makes infection more likely.
- D. wash the burn with soap and water to remove the oil.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct-because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn
A transfer truck carrying toxic chemicals derails, spilling the contents and emitting toxic fumes over several miles. As a result, many of the area residents complain of nausea, vomiting, and headache. According to the agent-host model, the host is:
- A. The train carrying the toxic chemicals
- B. Toxic fumes emitted by the derailed box cars
- C. Physical problems experienced by the residents
- D. The residents living in the area
Correct Answer: D
Rationale: In the agent-host model, the host is the affected individual (residents). The toxic fumes are the agent, and symptoms are the outcome.
A client is admitted with the following symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client has received 80 mg of furosemide (Lasix).
Which of the following nursing observations is MOST important to report to the next shift?
- A. Complaints of nausea and vomiting.
- B. Urine output of 200 cc in 2 hours.
- C. Quiet and withdrawn behavior after lunch.
- D. Blood pressure changes from 160/90 to 150/90.
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read the answers for clues. (1) further signs and symptoms of right-sided heart failure; not a priority (2) correct-furosemide is diuretic, which warrants close observation of the client's urine output (3) further signs and symptoms of right-sided heart failure; not a priority (4) may occur as a result of volume loss, but is not a priority over answer choice #2