Nokea
The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first?
- A. Wrap the left hand with towels and apply pressure.
- B. Instruct the friend to hold his hand above his head.
- C. Apply pressure to the radial artery of the left hand.
- D. Go into the friend's house and call 911.
Correct Answer: A
Rationale: Applying pressure with towels controls bleeding, the priority in traumatic amputation. Elevation is secondary, radial pressure is less effective, and calling 911 delays hemorrhage control.
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With the assistance of the translator, the nurse correctly instructs the client to use which technique when picking something up?
- A. Squat with the knees bent.
- B. Keep both feet together.
- C. Lift with the arms extended.
- D. Bend from the waist.
Correct Answer: A
Rationale: Squatting with knees bent uses leg muscles to lift, reducing spinal strain and protecting the surgical site post-laminectomy. Bending from the waist or other techniques risks reinjury.
The nurse identifies the concept of impaired functional ability for a client diagnosed with rheumatoid arthritis. Which intervention should the nurse implement?
- A. Teach the client to apply antiembolism (TED) hose.
- B. Administer the nonsteroidal medication before the morning meal.
- C. Encourage the client to perform low-impact exercises daily.
- D. Refer the client to occupational therapy for gait training.
Correct Answer: C
Rationale: Low-impact exercises maintain joint function in RA, addressing impaired ability. TED hose are for DVT, NSAIDs are for pain, and OT is for specific tasks, not gait.
The nurse is providing discharge teaching to the 12-year-old with a fractured humerus and the parents. Which information should the nurse include regarding cast care?
- A. Keep the fractured arm at heart level.
- B. Use a wire hanger to scratch inside the cast.
- C. Apply an ice pack to any itching area.
- D. Explain foul smells are expected occurrences.
Correct Answer: A
Rationale: Keeping the arm at heart level reduces edema in a casted humerus. Wire hangers risk skin damage, ice is for swelling not itching, and foul smells indicate infection.
The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first?
- A. The client with a total knee replacement who is complaining of a cold foot.
- B. The client diagnosed with osteoarthritis who is complaining of stiff joints.
- C. The client who needs to receive a scheduled intravenous antibiotic.
- D. The client diagnosed with back pain who is scheduled for a lumbar myelogram.
Correct Answer: A
Rationale: A cold foot post-knee replacement suggests vascular compromise, requiring urgent assessment to prevent tissue damage. Stiff joints, antibiotics, and myelogram prep are lower priority.
The school nurse is completing spinal screenings. Which data require a referral to an HCP?
- A. Bilateral arm lengthening while bending over at the waist.
- B. A deformity which resolves when the head is raised.
- C. Equal spacing of the arms and body at the waist.
- D. A right arm lower than the left while bending over at the waist.
Correct Answer: D
Rationale: Asymmetrical arm positioning (right lower than left) suggests scoliosis, requiring HCP referral. Symmetrical arms, resolving deformities, and equal spacing are normal.