Nokea
The day after an amputation, the client begins to hemorrhage from his stump. What action should the nurse take first?
- A. Apply a pressure dressing to the stump
- B. Place a tourniquet above the stump
- C. Notify the physician
- D. Apply an ice pack to the stump
Correct Answer: A
Rationale: Applying a pressure dressing is the first action to control hemorrhage, followed by notifying the physician.
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To immobilize the suspected fracture, how should the nurse apply a splint?
- A. Below the knee to above the hip
- B. Above the knee to below the hip
- C. Above the ankle to below the knee
- D. Below the ankle to above the knee
Correct Answer: C
Rationale: A suspected tibia fracture requires splinting from above the ankle to below the knee to stabilize the fracture site without unnecessarily immobilizing the hip or knee, which could restrict mobility or complicate transport.
Which statement to the nurse indicates a good understanding by the client of the use of methotrexate and cyclosporine?
- A. I am having an exacerbation of symptoms so two medications are needed.
- B. Cyclosporine is given to enhance the effect of the methotrexate.
- C. Methotrexate and cyclosporine together decrease unwanted side effects.
- D. My symptoms are severe enough to indicate the use of two strong medications.
Correct Answer: D
Rationale: Severe symptoms may necessitate combination therapy with methotrexate and cyclosporine, both potent immunosuppressants, to control rheumatoid arthritis. Cyclosporine does not enhance methotrexate, and side effects are not necessarily reduced.
Which intervention(s) should the nurse include in the child's plan of care immediately following insertion of a ventriculoperitoneal (VP) shunt for treatment of hydrocephalus?
- A. Maintain the head of the bed in an elevated position.
- B. Ensure that the child minimizes movement of the extremities.
- C. Provide a pressure dressing over the cephalic insertion site.
- D. Maintain a flat position and reposition the child every 2 hours.
Correct Answer: D
Rationale: Maintaining a flat position and repositioning every 2 hours helps prevent complications and ensures shunt function post-VP shunt insertion.
When reviewing the chart of a 25-year-old male, the nurse reads that the client was diagnosed with an osteosarcoma of the distal femur. Which statement indicates the nurse's correct interpretation of the client's diagnosis?
- A. The tumor originated elsewhere in the client's body and metastasized to the bone.
- B. Osteosarcoma is the most common and most often fatal primary malignant bone tumor.
- C. The only treatment for osteosarcoma is a leg amputation well above the tumor growth.
- D. The tumor is nonmalignant;it can be excised and the bone replaced with a bone graft.
Correct Answer: B
Rationale: B. Osteosarcoma is a malignant primary tumor of the bone, appearing most frequently in males between 10 and 25 years (when bones grow rapidly). Prognosis depends on whether the tumor has metastasized to the lungs, but it is often fatal.
The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a nonmodifiable risk factor?
- A. Calcium deficiency.
- B. Tobacco use.
- C. Female gender.
- D. High alcohol intake.
Correct Answer: C
Rationale: Female gender is a nonmodifiable risk factor for osteoporosis due to lower bone density post-menopause. Calcium deficiency, tobacco, and alcohol are modifiable.