Nokea
The client is about to go to surgery but is still wearing a class ring. Which nursing action is most appropriate regarding care of the client's valuables?
- A. Put the ring in the bedside stand.
- B. Tape the ring to the client's finger.
- C. Give the ring to a security guard.
- D. Take the ring to the hospital safe.
Correct Answer: D
Rationale: Valuables like a ring should be secured in the hospital safe to prevent loss or theft during surgery. Leaving it in the bedside stand is insecure, taping it risks circulation issues, and giving it to a security guard is not standard protocol.
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Which statement by the nurse provides the best explanation about the purpose of antiembolism stockings?
- A. Antiembolism stockings prevent blood from pooling in the legs.
- B. Antiembolism stockings reduce blood flow to the exercises.
- C. Antiembolism stockings keep the blood pressure lower in the legs.
- D. Antiembolism stockings keep the blood vessels constricted.
Correct Answer: A
Rationale: Antiembolism stockings apply graduated compression to promote venous return, preventing blood pooling and reducing the risk of deep vein thrombosis in immobile clients. The other options are inaccurate.
The nurse is caring for the client involved in an MVA who sustained an unstable pelvic fracture. Which HCP order should be the nurse's priority?
- A. Urinalysis and culture and sensitivity
- B. Blood alcohol level and toxicology screen
- C. Computed tomography (CT) scan of the pelvis
- D. Give two units of cross-matched whole blood
Correct Answer: D
Rationale: D. Significant blood loss occurs because the pelvis is a highly vascular area. A type and cross-match must be completed prior to administering blood, which takes time.
The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider immediately?
- A. Localized edema and discoloration occurring hours after the injury.
- B. Generalized weakness and increasing sensitivity to touch.
- C. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain.
- D. Pain relieved after taking four (4) mg hydromorphone, a narcotic analgesic.
Correct Answer: C
Rationale: Absent pulses and increasing pain suggest compartment syndrome or arterial occlusion, requiring urgent HCP notification. Edema is expected, weakness is nonspecific, and pain relief is positive.
The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement?
- A. Monitor the continuous passive motion machine.
- B. Apply thigh-high TED hose bilaterally.
- C. Place the abductor pillow between the legs.
- D. Encourage the family to perform ADLs for the client.
Correct Answer: A
Rationale: Monitoring the CPM machine ensures proper knee flexion/extension post-TKR. TED hose are standard, abductor pillows are for THR, and family ADL performance hinders independence.
Which intervention should the nurse implement when caring for the child with an Ilizarov external fixator applied to a lower extremity for bone lengthening?
- A. Loosening the bolts and lengthening the rods on the fixator every other day
- B. Cleansing the external fixator pin sites with sterile saline twice daily
- C. Discouraging the child from bearing any weight on the involved extremity
- D. Removing sections of the fixator apparatus when the child is positioned in bed
Correct Answer: B
Rationale: Regular cleansing of pin sites with sterile saline prevents infection in an Ilizarov fixator.