Nokea
Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?
- A. Outline the area with ink and check it every 15 minutes to see if the area has increased
- B. Notify the healthcare provider immediately
- C. Apply a new cast to stop the bleeding
- D. Elevate the limb to reduce blood flow
Correct Answer: A
Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast.
Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.
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A client with a postoperative wound that eviscerated yesterday has an elevated temperature. What is the most important intervention for the nurse to implement?
- A. Initiate contact isolation.
- B. Obtain a wound swab for culture and sensitivity.
- C. Assess temperature every 4 hours.
- D. Use alcohol-based solutions for hand hygiene.
Correct Answer: B
Rationale: Obtaining a wound swab for culture and sensitivity is the most important intervention in this situation. It helps identify the presence of infection in the postoperative wound that could be causing the elevated temperature. By obtaining a wound swab, healthcare providers can determine the appropriate treatment needed to address any infection. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case. Assessing temperature (Choice C) is important but does not directly address the underlying cause of the elevated temperature. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but is not the most crucial intervention in this scenario.
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding requires immediate intervention?
- A. Crepitus around the tracheostomy site
- B. Dry and cracked tracheostomy site
- C. Mucous plugging of the tracheostomy tube
- D. Yellowing of the skin around the tracheostomy site
Correct Answer: C
Rationale: Mucous plugging of the tracheostomy tube is the most concerning assessment finding in a client with a tracheostomy. It can lead to airway obstruction, which requires immediate intervention to ensure the client's airway remains patent. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but is not as urgent as a blocked airway. A dry and cracked tracheostomy site may indicate poor skin integrity but does not pose an immediate threat to the client's airway. Yellowing of the skin around the tracheostomy site could suggest a localized infection, but it is not as critical as a potential airway obstruction caused by mucous plugging.
A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during a prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?
- A. Leakage around the catheter insertion site.
- B. Pink-tinged urine in the drainage bag.
- C. Client reports discomfort at the catheter site.
- D. Decreased urine output in the last hour.
Correct Answer: A
Rationale: The correct answer is A. Leakage around the catheter insertion site may indicate a problem with the catheter placement or function, requiring immediate intervention. Pink-tinged urine in the drainage bag is expected due to the continuous bladder irrigation. Discomfort at the catheter site is common after the procedure. Decreased urine output in the last hour may be due to the continuous bladder irrigation and doesn't require immediate intervention.
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?
- A. Bruises on arms and legs
- B. Round and tight abdomen
- C. Pitting edema in lower legs
- D. Capillary refill of 8 seconds
Correct Answer: D
Rationale: In this situation, the client's capillary refill of 8 seconds is the assessment finding that warrants immediate intervention by the nurse. A capillary refill greater than 3 to 5 seconds indicates poor perfusion, which could be a sign of inadequate circulation and oxygenation. Checking capillary refill is a quick and useful way to assess peripheral perfusion. Bruises on arms and legs may indicate a bleeding disorder but are not as urgent as addressing poor perfusion. A round and tight abdomen could suggest ascites, which is already known in this case. Pitting edema in lower legs is a common finding in malnutrition and ascites but does not require immediate intervention as poor capillary refill does.
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which intervention should the nurse implement first?
- A. Encourage fluid intake to thin secretions.
- B. Administer a mucolytic agent.
- C. Increase humidity in the client's room.
- D. Perform deep suctioning as needed.
Correct Answer: C
Rationale: Increasing humidity in the client's room is the first priority in managing thick, tenacious secretions in a client with a tracheostomy to facilitate airway clearance. This intervention helps to moisten secretions, making them easier to clear. Encouraging fluid intake (Choice A) can be beneficial, but increasing humidity should be addressed first. Administering a mucolytic agent (Choice B) and performing deep suctioning (Choice D) are interventions that can be considered after addressing humidity if necessary, but they are not the initial priority.