Nokea
A client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting.
It is MOST important for the nurse to
- A. assess drainage from Penrose drains.
- B. observe dressings for signs of excessive bleeding.
- C. elevate the stump for no less than 40 hours.
- D. provide cast care to the affected extremity.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of each implementation. (1) drains not usually used with amputations (2) rigid cast dressing frequently used to create a socket for prosthesis (3) elevation of extremity unnecessary, rigid cast dressing prevents swelling (4) correct-cast applied to provide uniform compression, prevent pain and contractures
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An adult who is receiving methotrexate for rheumatoid arthritis asks the nurse why she is receiving methotrexate. What should the nurse include when responding?
- A. Methotrexate is given to help control the pain of rheumatoid arthritis.
- B. The drug is antipyretic and helps control the fevers associated with rheumatoid arthritis.
- C. Rheumatoid arthritis is an autoimmune disorder. Methotrexate is an immunosuppressant.
- D. The drug helps to repair cartilage that is damaged when a person has rheumatoid arthritis.
Correct Answer: C
Rationale: Methotrexate suppresses the autoimmune response in rheumatoid arthritis, reducing joint inflammation and damage. It is not primarily for pain, fever, or cartilage repair.
A client with bipolar disorder receives Eskalith (lithium carbonate) bid. Which observation is associated with lithium toxicity?
- A. Hyporeflexia
- B. Akathesia
- C. Ataxia
- D. Petechiae
Correct Answer: C
Rationale: Ataxia , or impaired coordination, is a sign of lithium toxicity. Hyporeflexia is not typical. Akathesia is restlessness, often linked to antipsychotics. Petechiae indicate bleeding issues, not lithium toxicity.
The nurse is to administer the daily dose of digoxin to an adult client. What is it essential for the nurse to do before administering the medication?
- A. Check the client's temperature
- B. Check the client's blood pressure
- C. Check the client's respirations
- D. Check the client's apical pulse
Correct Answer: D
Rationale: Digoxin slows heart rate; checking the apical pulse ensures it's above 60 bpm to avoid bradycardia. Temperature, blood pressure, and respirations are less critical.
A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is to
- A. provide an avenue for nutrients to flow past an obstructed area.
- B. prevent fluid and gas accumulation in the stomach.
- C. administer drugs that can be absorbed directly from the inTest inal mucosa.
- D. remove fluid and gas from the small inTest ine.
Correct Answer: D
Rationale: Miller-Abbott tube provides for inTest inal decompression; inTest inal tube is often used for treatment of paralytic ileus
A newborn is to be discharged in the AM.
The nurse should teach the child's mother to perform which of the following actions?
- A. Apply a sterile gauze dressing with petroleum jelly to the cord.
- B. Position the diaper over the umbilicus to keep it dry.
- C. Clean the cord several times a day and expose it to air frequently.
- D. Apply erythromycin ointment to the cord several times a day.
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) appropriate for circumcision (2) will keep the area moist; the diaper should be placed below the umbilicus (3) correct-encourages drying and helps to prevent infection (4) antibiotic ointment is unnecessary