Nokea
The first priority to care for the patient with a new fracture includes assessing
- A. Respiratory rate and effort, as well as pulse.
- B. The fracture site for bleeding.
- C. For signs of infection at the wound site of an open fracture.
- D. For circulation and sensation distal to the fracture site.
Correct Answer: D
Rationale: Assessing circulation and sensation ensures no compromise to distal structures.
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When assessing the health beliefs and practices of an older Hispanic adult, the nurse observes that the client uses a traditional folk healer to manage health problems. How would you respond?
- A. Respectfully acknowledge the practice and integrate it where possible.
- B. Discredit the folk healer's methods.
- C. Insist on conventional medical treatment only.
- D. Ignore the client's preference.
Correct Answer: A
Rationale: Respecting and integrating traditional practices fosters trust and collaboration in care delivery.
Which teaching strategies should the nurse plan to use for a baby boomer patient (select all that apply)?
- A. Podcast
- B. Role playing
- C. Group teaching
- D. Lecture-discussion
Correct Answer: B
Rationale: The correct answers are 'Role playing,' 'Group teaching,' and 'Lecture-discussion.' Baby boomers often prefer interactive and structured learning environments. Podcasts and games may not resonate as well with this demographic.
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct Answer: A
Rationale: Step 1: Increased respiratory rate from 18 to 44/min indicates potential respiratory distress, a serious complication post-fracture.
Step 2: Rapid breathing can signify hypoxemia, pulmonary embolism, or infection, requiring immediate intervention.
Step 3: Increased oral temperature and blood pressure within normal range are not as critical as respiratory distress.
Step 4: A slight increase in heart rate is common after a fracture and not indicative of a serious complication.
What does the nurse give priority to assessing immediately following Mr. Singer’s total laryngectomy?
- A. Elimination patterns
- B. Level of pain
- C. Gag reflex
- D. Respiratory status
Correct Answer: D
Rationale: Respiratory status is critical due to the altered airway anatomy.
Which teaching strategies should be used when it is difficult to reach the desired goals of the session (select all that apply)?
- A. DVD
- B. Role play
- C. Discussion
- D. Printed material
Correct Answer: B
Rationale: The correct answers are 'Role play,' 'Discussion,' and 'Lecture-discussion.' These strategies encourage active participation and engagement, which can help overcome barriers to achieving learning goals. DVDs and printed materials may not engage the patient as effectively in challenging situations.