Nokea
The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room?
- A. Transfer the client to a cart with manually suspended traction.
- B. Call the surgeon to request an order to temporarily remove the traction.
- C. Send the client on his bed with extra help to stabilize the traction.
- D. Remove the traction and send the client on a cart.
Correct Answer: C
Rationale: Transporting on the bed with extra help maintains traction stability, preventing fracture displacement.
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In the oliguric phase of acute renal failure, the nurse should assess the client for:
- A. Pulmonary edema.
- B. Metabolic alkalosis.
- C. Hypotension.
- D. Hypokalemia.
Correct Answer: A
Rationale: Pulmonary edema is a risk in the oliguric phase due to fluid overload from reduced urine output.
The nurse is providing discharge instructions to a client who underwent left eye cataract surgery with a lens implant. Which statement by the client would indicate a correct understanding of the teaching?
- A. I should avoid getting water in the eye for 3 to 7 days after surgery.'
- B. It is okay for me to resume normal chores such as vacuuming.'
- C. It is okay for me to have green or yellow, thick drainage from the eye.'
- D. I may take aspirin for any pain I may experience.'
Correct Answer: A
Rationale: Avoiding water in the eye for 3-7 days post-cataract surgery prevents infection. Heavy chores like vacuuming, abnormal drainage, and aspirin use (which risks bleeding) are contraindicated.
The client with vasospastic disorder (Raynaud's phenomenon) complains of cold and numbness in her fingers. The nurse assesses the client for effects of vasoconstriction. Which of the following is an early sign of vasoconstriction?
- A. Cyanosis
- B. Gangrene
- C. Pallor
- D. Rubor
Correct Answer: C
Rationale: Pallor is an early sign of vasoconstriction in Raynaud's, as reduced blood flow causes the skin to turn white. Cyanosis occurs later with prolonged ischemia, gangrene is a late complication, and rubor (redness) occurs during the hyperemic phase after vasospasm resolves.
Which of the following guidelines reflects the current American Cancer Society recommendations for screening for colon cancer in individuals who are not at high risk?
- A. Annual digital rectal examination should begin at age 40.
- B. Annual fecal testing for occult blood should begin at age 50.
- C. Individuals should obtain a baseline barium enema at age 40.
- D. Individuals should obtain a baseline colonoscopy at age 45.
Correct Answer: B
Rationale: Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they recommend the nurse to the need for such diagnostic testing, or are considered to be at high risk. CN: Health promotion and maintenance; CL: Apply
The nurse is teaching a client with a spinal fusion about body mechanics. Which client statement indicates understanding?
- A. I'll bend at the waist to pick up objects.'
- B. I'll keep my back straight when lifting.'
- C. I'll twist my torso to reach objects.'
- D. I'll carry heavy items close to my chest.'
Correct Answer: B
Rationale: Keeping the back straight during lifting protects the surgical site and maintains spinal alignment.