Nokea
The emergency department nurse is caring for a client with a compound fracture of the right ulna. Which interventions should the nurse implement? List in order of priority.
- A. Apply a sterile, normal saline-soaked gauze to the arm.
- B. Send the client to radiology for an x-ray of the arm.
- C. Assess the fingers of the client’s right hand.
- D. Stabilize the arm at the wrist and the elbow.
- E. Administer a tetanus toxoid injection.
Correct Answer: C,A,D,B,E
Rationale: Priority: 1) Assess fingers (neurovascular status); 2) Cover wound with sterile gauze (prevent infection); 3) Stabilize arm (reduce damage); 4) X-ray (confirm fracture); 5) Tetanus (prevent infection).
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The nurse is caring for a client with a newly applied plaster cast. How should the nurse touch and move the wet cast?
- A. Use the palms of the hands
- B. Use the fingertips only
- C. Use a towel sling
- D. Touch the cast only on the petals at the edges
Correct Answer: A
Rationale: Using the palms prevents indentations in a wet cast, which could cause skin irritation. Fingertips create indentations, a towel sling is inappropriate, and petaling occurs after drying.
The nurse is caring for the client after a right TKR. To prevent circulatory complications, the nurse should ensure that the client is performing which action?
- A. Flexing both feet and exercising uninvolved joints every hour while awake
- B. Using the continuous passive motion device (CPM) every 2 hours for 30 minutes
- C. Being assisted up to a chair as soon as the effects of anesthesia have worn off
- D. Using the trapeze to lift off the bed and then rotating each leg intermittently
Correct Answer: A
Rationale: A. Dorsiflexion of the foot promotes muscle contraction, which compresses veins. This reduces venous stasis and risk of thrombus formation. It should be performed every hour while awake.
The nurse is caring for the client 2 days post-right THR in which the traditional posterior approach was used. Which interventions should the nurse implement?
- A. Checks that an elevated toilet seat is in place and assists the client to the bathroom using a walker
- B. Removes the wedge pillow at the client's request and places pillows to maintain right leg adduction
- C. Reinfuses the 400-mL wound autotransfusion drainage system returns that collected in the past 24 hours
- D. Assists the client to get out of bed on the left side so the client can stand to place and use the urinal
Correct Answer: A
Rationale: A. The client should be able to ambulate with the use of a walker. An elevated toilet seat is used to prevent hip flexion of greater than 90 degrees when the client sits.
The college student consults the clinic nurse for advice on managing lower back pain. Which instructions should the nurse include? Select all that apply.
- A. Continue routine activity within your pain tolerance while paying attention to correct posture.
- B. Temporarily avoid lifting and other activities that increase mechanical stress on your spine.
- C. When sleeping on your side, flex your hips and knees and place a pillow between your knees.
- D. Stay at home for 1 week on bedrest to minimize physical activity and straining your back.
- E. Stand intermittently during classes, and sit with a soft support at the small of your back.
Correct Answer: A,B,C,E
Rationale: A. Remaining active is best. Using good posture will minimize back strain. B. Mechanical stress can increase pain. Prolonged unsupported sitting, heavy lifting, and bending or twisting the back, especially while lifting, should be avoided. C. Using pillows and hip and knee flexion promotes lumbar flexion and back alignment. E. Prolonged sitting should be avoided because fatigue contributes to spasm of the back muscles. Lordosis can be decreased by using a soft support at the small of the back.
During a physical examination of the 1-month-old, the nurse notes that the infant has blue sclerae. The nurse should further assess for signs and symptoms of which disorder?
- A. Juvenile rheumatoid arthritis (JRA)
- B. Tay-Sachs disease
- C. Duchenne muscular dystrophy (DMD)
- D. Osteogenesis imperfecta (OI)
Correct Answer: D
Rationale: Blue sclerae are a hallmark of osteogenesis imperfecta due to thin connective tissue.