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An hour ago the HCP split the client's forearm cast due to severe arm pain, throbbing, and tingling. Which most important action should be taken by the nurse when the client's symptoms return?
- A. Administer an intravenous pain medication.
- B. Notify the health care provider immediately.
- C. Cut the cast padding and spread the cast Men
- D. Elevate the arm on pillows above the heart level.
Correct Answer: B
Rationale: B. The nurse should notify the HCP immediately because these symptoms suggest compartment syndrome, which is a medical emergency.
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Which action by the nurse would be most appropriate for a child newly diagnosed with Reye's syndrome?
- A. Determining if the child had a bacterial infection recently
- B. Placing the child in a private room with droplet precautions
- C. Taking the child to the unit's play area to interact with others
- D. Assessing for signs of bleeding and for prolonged bleeding time
Correct Answer: D
Rationale: Assessing for bleeding is critical in Reye's syndrome due to liver dysfunction and potential coagulopathy.
Two unlicensed assistive personnel (UAP) are using the transfer board to move the client from the bed to the wheelchair. Which action should the nursing take?
- A. Take no action because this is the correct procedure for transferring a client.
- B. Instruct the UAPs not to use a transfer board when moving the client.
- C. Tell the UAPs to use the bed scale sling to move the client to the chair.
- D. Request the UAPs to stop and come to the nurse’s station immediately.
Correct Answer: A
Rationale: Using a transfer board is safe and appropriate for bed-to-wheelchair transfers; no action is needed. Other options are incorrect or unsafe.
The nurse writes a concept of 'impaired mobility' for a client diagnosed with a fractured right hip. Which would the nurse include in the plan of care? Select all that apply.
- A. Request a physical therapy referral.
- B. Administer enoxaparin (Lovenox) subcutaneously.
- C. Utilize a gait belt when ambulating the client.
- D. Assess the client’s pain levels on a 1-to-10 scale.
- E. Provide a high-carbohydrate, high-fat, high-sodium diet.
Correct Answer: A,B,C,D
Rationale: PT referral, enoxaparin, gait belt, and pain assessment promote mobility and prevent complications in hip fracture. High-carb/fat/sodium diet is inappropriate.
When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client?
- A. Lying supine
- B. Sitting in a chair
- C. Lying on the side
- D. Standing to shower
Correct Answer: D
Rationale: Standing to shower is least desirable post-below-the-knee amputation due to the risk of falls and weight-bearing on the stump, which could disrupt healing. Other positions are safer.
Which interventions should the nurse implement for a child with a newly applied fiberglass hip-Spica cast?
- A. Use a hair dryer on a low setting to help dry the cast.
- B. Place on a Bradford frame for elevation off the bed.
- C. Place pillows to support the child's lower extremities.
- D. Turn the child every 2 hours and monitor the CMS.
- E. Petal the perineal area and other edges of the cast.
Correct Answer: C,D,E
Rationale: Pillows provide support, turning prevents pressure sores, and petaling protects skin around cast edges.