Nokea
The experienced nurse observes the new nurse caring for the client who is in skeletal traction to stabilize a proximal femur fracture prior to surgery. Which observation by the experienced nurse indicates the new nurse needs additional orientation?
- A. Positions the client so the client's feet stay clear of the bottom of the bed
- B. Checks ropes so that they are positioned in the wheel groves of the pulleys
- C. Removes weights from ropes until the weights hang free of the bed frame
- D. Performs pin site care with chlorhexidine solution once during the 8-hour shift
Correct Answer: C
Rationale: C. Weights should be hanging freely, but weights should never be removed (unless a life-threatening situation occurs) because removal could result in injury and defeats the purpose of the traction. The lengths of the ropes need to be adjusted so the weights do not rest on the bed frame.
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Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate therapy?
- A. Constipation
- B. Dry mouth
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores are a common side effect of methotrexate due to its effect on mucosal cells.
The occupational health nurse is preparing an in-service for a group of workers in a warehouse. Which information should be included to help prevent on-the-job injuries?
- A. Increase sodium and potassium in the diet during the winter months.
- B. Use the large thigh muscles when lifting and hold the weight near the body.
- C. Use soft-cushioned chairs when performing desk duties.
- D. Have the employee arrange for assistance with household chores.
Correct Answer: B
Rationale: Using thigh muscles and keeping weight close to the body promotes proper lifting mechanics, reducing back strain. Diet, chair cushioning, and household chores are unrelated to workplace injury prevention.
How can the nurse best support the wet cast while the physician wraps the arm with rolls of wet plaster?
- A. By using a soft mattress
- B. By resting it on a firm surface
- C. By using the client's knee on the fingers
- D. By using the palms of the hands
Correct Answer: D
Rationale: Using the palms of the hands to support the wet cast prevents indentations that could cause pressure points, ensuring the cast maintains its shape. A soft mattress or fingers may deform the cast, and a firm surface is less precise.
The HCP's progress note states that the infant with meningitis is in an opisthotonus position. What should the nurse observe when performing an assessment?
- A. Resistance with specific leg movement
- B. Knee or hip flexion with head flexion
- C. A high-pitched cry with neck flexion
- D. Hyperextension of the head and neck
Correct Answer: D
Rationale: Opisthotonus is characterized by severe hyperextension of the head and neck, often seen in meningitis.
What is true about absence seizures in children?
- A. For most children, absence seizures stop during early teen years.
- B. Absence seizures rarely progress to other seizures.
- C. Teachers often note signs of absence seizures, but seeing them is not adequate for diagnosis.
- D. Absence seizures usually exist in isolation; usually the child has no other neurological condition.
Correct Answer: A
Rationale: Most children outgrow absence seizures during their early teen years.