Nokea
Hazards of improper splinting include:
- A. aggravation of a bone or joint injury
- B. reduced distal circulation
- C. delay in transport of a client with a life-threatening injury
- D. all of the above
Correct Answer: D
Rationale: Improper splinting can worsen injuries, impair circulation, and delay critical transport, posing significant risks to the client.
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The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 5 minutes if your NG residual is below 50 mLs.
- C. You can lie down in about 30 minutes.
- D. You can lie down now.
Correct Answer: C
Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure the medications are absorbed.
To remove a client's gown when she has an intravenous line, the nurse should:
- A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown.
- B. cut the gown with scissors.
- C. thread the bag and tubing through the gown sleeve, keeping the line intact.
- D. temporarily disconnect the tubing from the intravenous container and thread it through the gown.
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.
An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?
- A. inability to turn, cough, and breathe deeply
- B. inability to communicate pain
- C. inability to ambulate freely
- D. inability to use a bedside commode
Correct Answer: B
Rationale: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client.
The nurse is caring for the client with a stage III pressure ulcer to the right heel. Which actions should the nurse plan? Select all that apply.
- A. Encourage foods high in vitamin C such as orange juice
- B. Premedicate with analgesics prior to dressing changes
- C. Monitor pedal pulses and capillary refill of affected extremity
- D. Use hydrogen peroxide for cleaning of the ulcer wound
- E. Turn and reposition the client every 1 to 2 hours
- F. Elevate the extremity on pillows, keeping the heel off the pillow
Correct Answer: A,B,C,E,F
Rationale: A: Vitamin C aids wound healing. B: Analgesics improve comfort. C: Pulse checks detect vascular issues. E: Repositioning prevents further breakdown. F: Elevation and offloading reduce pressure. D: Hydrogen peroxide harms tissue.
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:
- A. notify the physician of the drainage.
- B. change the dressing.
- C. reinforce the dressing.
- D. apply an abdominal binder.
Correct Answer: C
Rationale: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.