Nokea
Of the following emergency measures, which one should the nurse perform first?
- A. Check the victim's breathing.
- B. Cover the victim with a blanket.
- C. Move the victim to the curb.
- D. Assess the victim for injuries.
Correct Answer: A
Rationale: In an emergency, the nurse must first assess the victim's breathing to ensure airway patency and adequate oxygenation, following the ABCs (Airway, Breathing, Circulation) of basic life support. Other actions are secondary.
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The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement?
- A. Assess the client's nutritional status.
- B. Refer the client to an occupational therapist.
- C. Determine if the client is allergic to IVP dye.
- D. Start a 22-gauge Angiocath in the right arm.
Correct Answer: A
Rationale: Nutritional status assessment ensures adequate healing post-amputation, critical in diabetes. OT referral is postoperative, IVP dye is irrelevant, and a 22-gauge IV is too small for surgery.
The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests should the nurse expect the health-care provider to order to R/O osteoarthritis?
- A. Full-body magnetic resonance imaging scan.
- B. Serum studies for synovial fluid amount.
- C. X-ray of the affected joints.
- D. Serum erythrocyte sedimentation rate (ESR).
Correct Answer: C
Rationale: X-rays reveal OA characteristic joint space narrowing and osteophytes. MRI is excessive, synovial fluid studies are not routine, and ESR is for inflammatory conditions, not OA.
What equipment is best for preventing external rotation of the operative leg when caring for a client with a total hip replacement?
- A. A footboard
- B. A trochanter roll
- C. A turning sheet
- D. A foam mattress
Correct Answer: B
Rationale: A trochanter roll placed along the hip prevents external rotation of the operative leg, maintaining proper alignment post-hip replacement. The other options do not specifically address rotation.
The client is 12-hours post-lumbar laminectomy. Which nursing interventions should be implemented?
- A. Assess ability to void and log roll the client every two (2) hours.
- B. Medicate with IV steroids and keep the bed in a Trendelenburg position.
- C. Place sandbags on each side of the head and give cathartic medications.
- D. Administer IV anticoagulants and place on O2 at eight (8) L/min.
Correct Answer: A
Rationale: Post-lumbar laminectomy, assessing voiding prevents urinary retention, and log rolling maintains spinal alignment. Steroids/Trendelenburg, sandbags/cathartics, and anticoagulants/O2 are inappropriate without specific indications.
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement?
- A. Adjust the patient-controlled analgesia (PCA) machine for a lower dose.
- B. Ensure the weights of the Buck's traction are off the floor and hang freely.
- C. Raise the head of the bed to 45 degrees and the foot to 15 degrees.
- D. Turn the client on the affected leg using pillows to support the other leg.
Correct Answer: B
Rationale: Proper Buck’s traction alignment (weights off floor) reduces pain from misalignment. Adjusting PCA, bed positioning, or turning may worsen pain or are inappropriate.