Nokea
The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?
- A. Perform passive range of motion to the right leg
- B. Remove skeletal weights every shift to assess right leg
- C. Turn frequently from prone to supine positions
- D. Maintain skeletal pin sites and assess for signs of infection
Correct Answer: D
Rationale: The correct answer is D: Maintain skeletal pin sites and assess for signs of infection. This is important to prevent complications like infection, which can be severe. The nurse should regularly assess the pin sites for redness, swelling, or discharge. This intervention ensures early detection and prompt treatment of any signs of infection, reducing the risk of serious complications.
Choice A is incorrect because performing passive range of motion to the right leg may disrupt the traction and interfere with the healing process.
Choice B is incorrect because removing skeletal weights every shift can lead to loss of traction, compromising the fracture alignment and healing process.
Choice C is incorrect because turning the client frequently from prone to supine positions may also disrupt the traction and increase the risk of complications.
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A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?
- A. Place the child in a mist tent
- B. Obtain a sputum culture
- C. Prepare for an emergent tracheostomy
- D. Examine the child's oropharynx and report the findings to the healthcare provider
Correct Answer: A
Rationale: The correct answer is A: Place the child in a mist tent. This intervention is crucial in managing a child with croup, which presents with stridor, fever, and respiratory distress. Placing the child in a mist tent provides humidified air, which can help reduce airway inflammation and ease breathing. It is the first-line treatment for croup and should be initiated promptly to relieve the child's symptoms. Obtaining a sputum culture (B) is not necessary in this scenario as the child's presentation is consistent with croup, which is a clinical diagnosis. Preparing for an emergent tracheostomy (C) is an invasive procedure that should only be considered if other treatments fail. Examining the child's oropharynx (D) can be helpful but is not the most urgent intervention in this situation.
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a 'cottage cheese' appearance. Which prescription should the nurse implement first?
- A. Cleanse the perineum with warm soapy water 3 times per day
- B. Instill the first dose of nystatin (Mycostatin) vaginally per applicator
- C. Perform a glucose measurement using a capillary blood sample
- D. Obtain a blood specimen for sexually transmitted diseases (STDs)
Correct Answer: B
Rationale: The correct answer is B: Instill the first dose of nystatin (Mycostatin) vaginally per applicator. This is the appropriate action for a college student with symptoms of a vaginal infection with a 'cottage cheese' appearance discharge, which is indicative of a yeast infection (most likely caused by Candida). Nystatin is an antifungal medication effective against Candida, hence addressing the root cause of the infection. It is essential to start with the treatment first to alleviate the symptoms and prevent further complications.
Incorrect choices:
A: Cleansing the perineum with warm soapy water may provide some comfort but does not address the underlying infection.
C: Performing a glucose measurement is not necessary at this stage as the symptoms suggest a yeast infection, not diabetes.
D: Obtaining a blood specimen for STDs is not the priority in this case as the symptoms are indicative of a yeast infection, not an STD.
The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Partial thromboplastin time (PTT)
- D. Hemoglobin level
Correct Answer: C
Rationale: The correct answer is C: Partial thromboplastin time (PTT). PTT measures the effectiveness of heparin therapy by assessing the clotting time. With heparin being an anticoagulant, monitoring PTT helps ensure the client is within the therapeutic range to prevent clot formation. A - Platelet count assesses risk of bleeding, not heparin effectiveness. B - Prothrombin time (PT) is used to monitor warfarin therapy, not heparin. D - Hemoglobin level monitors for anemia, not heparin effectiveness.
A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?
- A. It dissolves blood clots
- B. It prevents the blood from clotting
- C. It thins the blood
- D. It decreases the risk of infection
Correct Answer: B
Rationale: The correct answer is B: It prevents the blood from clotting. Warfarin works as an anticoagulant by inhibiting the production of certain clotting factors in the liver. This prevents the formation of blood clots and reduces the risk of conditions like deep vein thrombosis or stroke. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones. Choice C is misleading as it does not actually "thin" the blood but affects its ability to clot. Choice D is unrelated to the mechanism of action of warfarin.
Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?
- A. Avoiding the administration of high levels of oxygen for extended periods.
- B. Administering a sedative at bedtime to slow the client's respiratory rate.
- C. Removing the nasal cannula during the night to prevent oxygen buildup.
- D. Running oxygen through a hydration source prior to administration.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. High levels of oxygen over a prolonged period can lead to oxygen toxicity.
2. Oxygen toxicity can cause lung damage and respiratory distress.
3. To prevent oxygen toxicity, it is crucial to monitor and limit the duration and amount of oxygen administered.
4. Therefore, avoiding the administration of high levels of oxygen for extended periods is the most effective intervention to prevent oxygen toxicity.
Summary of other choices:
B: Administering a sedative does not address the root cause of oxygen toxicity and can mask symptoms.
C: Removing the nasal cannula at night can lead to hypoxia and is not a safe practice.
D: Running oxygen through a hydration source does not prevent oxygen toxicity and is not a recognized intervention.