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Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- A. 16 year-old who had an open reduction of a fractured wrist 10 hours ago
- B. 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
- C. 72 year-old recovering from surgery after a hip replacement 2 hours ago
- D. 75 year-old who is in skin traction prior to planned hip pinning surgery.
Correct Answer: C
Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.
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The nurse is talking with the parent of an adolescent client with suspected bulimia nervosa. Which of the following statements by the client's parent would be consistent with bulimia nervosa?
- A. I have noticed my child cuts food into small pieces and pushes it around the plate.
- B. I found several empty boxes of laxatives in my child's bedroom.
- C. My child has lost 20 lb (9.1 kg) in the past 2 months.
- D. My child has stopped exercising.
Correct Answer: B
Rationale: Laxative abuse is a common purging behavior in bulimia nervosa. Cutting food and pushing it around is more typical of anorexia. Significant weight loss is less common in bulimia, as weight often fluctuates. Reduced exercise isn't characteristic.
The nurse is caring for a client with partial hearing loss. Which of the following actions will promote effective communication? Select all that apply.
- A. Dim lights to prevent overstimulation
- B. Directly face the client when speaking
- C. Ensure hearing aids are properly applied
- D. Provide written information to supplement conversation
- E. Raise voice to speak loudly to the client
Correct Answer: B,C,D
Rationale: Facing the client aids lip-reading, properly applied hearing aids optimize hearing, and written information reinforces verbal communication. Dimming lights may hinder lip-reading, and shouting distorts speech.
Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.
- A. I will clarify with my health care provider before taking enteric-coated medications.
- B. I will irrigate the colostomy to promote regular bowel movements.
- C. I will limit eating foods such as broccoli and cauliflower to reduce odor.
- D. I will restrict my fluid intake to 2,000 milliliters of fluid a day.
- E. I will wait for the pouch to become completely full before emptying the contents.
Correct Answer: A,C
Rationale: Enteric-coated medications may not dissolve properly in an ascending colostomy due to shorter intestinal transit time, requiring provider consultation. Limiting odor-causing foods like broccoli helps manage odor. Irrigation is typically for descending/sigmoid colostomies, not ascending. Fluid intake should be adequate (not restricted), and pouches should be emptied when one-third to half full to prevent leaks.
The physician has ordered an irrigation of the client's left ear for the removal of cerumen. To prevent vestibular stimulation, the fluid should be degrees Fahrenheit:
- A. 68
- B. 76
- C. 98
- D. 120
Correct Answer: C
Rationale: Cerumen is removed using a mixture of water and hydrogen peroxide at body temperature. Answers A and B are incorrect because they are too cold. Answer D is incorrect because it is too hot.
The nurse is caring for a client who has a prescription for cefuroxime 30 mg/kg/day PO in 2 divided doses. The client weighs 35 lb (15.9 kg). The nurse has cefuroxime 250 mg/5 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using 1 decimal place.
Correct Answer: 2.9
Rationale: Total daily dose: 30 mg/kg × 15.9 kg = 477 mg/day. Divided into 2 doses: 477 ÷ 2 = 238.5 mg/dose. Using 250 mg/5 mL: (238.5 mg ÷ 250 mg) × 5 mL = 4.77 mL. Per 2 doses: 4.77 ÷ 2 = 2.385, rounded to 2.9 mL per dose.