Nokea
The Jewish client with peripheral vascular disease is scheduled for a left AKA. Which question is most important for the operating room nurse to ask the client?
- A. Have you made any special arrangements for your amputated limb?'
- B. What types of food would you like to eat while you're in the hospital?'
- C. Would you like a rabbi to visit you while you are in the recovery room?'
- D. Will you start checking your other foot at least once a day for cuts?'
Correct Answer: A
Rationale: Jewish cultural practices may require special handling of amputated limbs (e.g., burial); this question respects beliefs. Food, rabbi visits, and foot checks are secondary.
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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).
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.
When preparing to meet with the parents and their 5-year-old child with autism, which behaviors should the nurse anticipate that the child might display?
- A. Polydactyly
- B. Leukoderma
- C. Poor eye contact
- D. Restricted interests
- E. Atypical language
Correct Answer: C,D,E
Rationale: Children with autism often exhibit poor eye contact, restricted interests, and atypical language patterns.
Which nursing assessment finding is the best indication that the client has an infection at the pin site?
- A. Serous drainage at the pin site
- B. Bloody drainage at the pin site
- C. Mucoid drainage at the pin site
- D. Purulent drainage at the pin site
Correct Answer: D
Rationale: Purulent (pus-like) drainage is the clearest sign of infection at the pin site, indicating bacterial presence. Serous, bloody, or mucoid drainage is less specific to infection.
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.