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The graduate nurse (GN) is caring for a client with a fractured femur in balanced suspension skeletal traction. Which action by the GN will require the precepting nurse to intervene?
- A. Encourages the client to drink plenty of water and choose high-fiber foods from the diet menu
- B. Lifts the traction weights while the unlicensed assistive personnel provide a bed bath and linen change
- C. Monitors the incision and pin insertion sites for erythema, drainage, and malodor
- D. Performs Doppler ultrasound pulse checks in the affected leg every hour for the first 24 hours after surgery
Correct Answer: B
Rationale: Lifting traction weights (B) disrupts alignment and healing, requiring intervention. Hydration and fiber (A), monitoring sites (C), and pulse checks (D) are appropriate.
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A nurse is assigned to a client who is newly admitted for treatment of a frontal lobe brain tumor. Which history offered by the family members would be recognized by the nurse as associated with the diagnosis, and communicated to the provider?
- A. My partner's breathing rate is usually below 12.
- B. I find the mood swings and the change from a calm person to being angry all the time hard to deal with.
- C. It seems our sex life is nonexistent over the past 6 months.
- D. In the morning and evening I hear complaints that reading is next to impossible from blurred print.
Correct Answer: B
Rationale: I find the mood swings and the change from a calm person to being angry all the time hard to deal with. Frontal lobe tumors affect emotions and judgment, causing mood swings and personality changes.
A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which
- A. increase the heart rate
- B. lead to dehydration
- C. are considered aerobic
- D. may be competitive
Correct Answer: B
Rationale: lead to dehydration. The client must take in adequate fluids before and during exercise periods.
The nurse is reinforcing teaching on self-administering ophthalmic lubricating ointment medication to a client with newly diagnosed Sjogren's syndrome. Which client statement indicates the need for further teaching?
- A. After applying the ointment, I'll close my eyes tightly and rub the lid for 2-3 minutes.
- B. I'll squeeze a thin strip of ointment on my lower eyelid, from the inner to the outer edge.
- C. I'll tilt my head back, pull my lower lid down, and look upward when administering the ointment.
- D. I'll use my ointment at bedtime and my eyedrops during the day.
Correct Answer: A
Rationale: Rubbing the eyes after applying ointment (A) can cause irritation or displace the medication, indicating a need for further teaching. The other statements (B, C, D) reflect correct administration techniques.
A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?
- A. Low hemoglobin
- B. Hypernatremia
- C. High serum creatinine
- D. Hyperkalemia
Correct Answer: A
Rationale: Low hemoglobin. Hemodialysis corrects electrolyte imbalances but does not improve anemia.
The nurse has taught the parent of a pediatric client who will be receiving growth hormone replacement therapy. Which of the following statements by the parent would require follow-up?
- A. The medication needs to be given at bedtime to be most effective.
- B. My child will achieve a height equal to peers after receiving therapy.
- C. The medication will be discontinued when my child's bone growth ceases.
- D. Routine x-rays may be required during therapy to monitor bone lengthening.
Correct Answer: B
Rationale: Expecting equal height to peers (B) is unrealistic, as outcomes vary. Bedtime dosing (A), discontinuation at bone closure (C), and x-rays (D) are correct.