Nokea
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture
For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Finding: Dyspnea
- A. Dyspnea
- B. Tingling sensation to right foot
- C. Increased pain at incision site
- D. Swelling at incision site
Correct Answer:
Rationale: Dyspnea is a hallmark of fat embolism syndrome due to pulmonary involvement.
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A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps?
- A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
- B. Check the medication administration record to verify the client's allergies.
- C. Slowly inject the medication into the site without aspirating.
- D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle.
- E. Ensure an air bubble is present in the prefilled enoxaparin syringe.
Correct Answer: B,E,A,D,C
Rationale: The sequence is: Verify allergies (B), check the air bubble (E), locate the site (A), pinch and inject at 90° (D), and inject slowly without aspirating (C) per enoxaparin protocol.
A nurse is preparing to perform tracheostomy care for a client. In which order should the nurse take the following steps?
- A. Ensure a method to communicate during the procedure.
- B. Wear clean gloves to remove the tracheostomy dressing.
- C. Clean the inner cannula using a small brush.
- D. Explain the procedure to the client.
- E. Apply clean tracheostomy ties.
Correct Answer: D,A,B,C,E
Rationale: The sequence is: Explain the procedure (D) to inform the client, ensure communication (A) during the process, remove the dressing with gloves (B), clean the cannula (C), and apply new ties (E). This order ensures safety and client comfort.
A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
- A. Have the client wear a surgical mask during transport.
- B. Wear an N95 mask while providing care to the client.
- C. Administer an influenza immunization to the client.
- D. Place the client in a negative airflow room.
Correct Answer: A
Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hr earlier. Which of the following changes should the nurse identify as the priority finding?
- A. Heart rate change from 110/min to 68/min
- B. Respiratory rate change from 12/min to 20/min
- C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg
- D. Temperature change from 36.6°C (97.9°F) to 38.8°C (101.9°F)
Correct Answer: C
Rationale: Using the ABCs, blood pressure dropping from 118/78 to 86/50 mm Hg signals potential shock or hypoperfusion, a circulation emergency requiring immediate assessment. Heart rate falling from 110 to 68 could reflect recovery (e.g., post-tachycardia) or bradycardia, but without symptoms, it's less urgent. Respiratory rate rising from 12 to 20 suggests compensation or distress, but circulation trumps breathing in acuity here. Temperature jumping to 38.8°C indicates fever, possibly infection, but hemodynamic instability is more immediately life-threatening. A systolic drop to 86 mm Hg risks organ perfusion, aligning with triage priorities hypotension could stem from bleeding, dehydration, or sepsis, needing rapid provider notification. This finding drives urgent intervention, making it the nurse's top concern.
A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?
- A. Having a total cholesterol level below 200 mg/dL increases my risk for a stroke.
- B. My risk for a stroke increases if my HbA1c level is 6 percent or less.
- C. My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke.
- D. I can decrease my risk for a stroke by losing excess weight.
Correct Answer: D
Rationale: Losing excess weight reduces stroke risk by improving cardiovascular health, a key factor in diabetes management. High cholesterol, uncontrolled HbA1c, and glucocorticoids increase, not decrease, stroke risk.