Nokea
The nurse applies warm compresses to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is:
- A. Less scaling on the skin.
- B. Decreased bruising.
- C. Improved circulation to the area.
- D. Decreased swelling in the area.
Correct Answer: C
Rationale: Warm compresses promote vasodilation, improving circulation to the area, which aids healing and reduces symptoms.
You may also like to solve these questions
The nurse is caring for a client with a history of glaucoma who is prescribed timolol (Timoptic) eye drops. The nurse should instruct the client to report which of the following side effects?
- A. Blurred vision.
- B. Bradycardia.
- C. Eye redness.
- D. Dry eyes.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bradycardia, which should be reported immediately.
Which of these clients is at greatest risk for falls?
- A. A 77 year old female client in a client room that has low glare floors.
- B. An 87 year old female client in a client room that has low glare floors.
- C. A 27 year old sedated male client.
- D. A 37 year old male client with impaired renal perfusion.
Correct Answer: B
Rationale: An 87-year-old female is at the greatest risk for falls due to age-related factors like decreased mobility, balance issues, and potential comorbidities, compared to younger or less impaired clients.
A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead ECG. Which action should the nurse take first?
- A. Obtain the 12-lead ECG.
- B. Draw the blood specimens.
- C. Apply the oxygen to the client.
- D. Schedule the chest x-ray study.
Correct Answer: C
Rationale: The first action would be to apply the oxygen because the client can be experiencing myocardial ischemia. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, oxygen is the priority to prevent further cardiac damage. Drawing the blood specimens would be done after oxygen administration and just before or after the ECG, depending on the situation. Although the chest x-ray can show cardiac enlargement, having the chest x-ray would not influence immediate treatment.
A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, 'My boyfriend has been beating me up once in a while since I became pregnant'”but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children.' Which of the following actions should be the priority by the nurse at this time?
- A. Contact a social worker for assistance and family counseling.
- B. Help the client make concrete plans for the safety of herself and her children.
- C. Tell the client and how anyone to hit her or her children.
- D. Provide the client with brochures on the statistics about violence against women.
Correct Answer: B
Rationale: Prioritizing safety planning protects the client and her children from further abuse.
The nurse assesses a 7-month-old infant's growth and development. Which behavior should the nurse consider unusual?
- A. Drinking from a cup and spilling little of the liquid.
- B. Raising the chest and upper abdomen off the bed with the hands.
- C. Imitating sounds that the nurse makes.
- D. Crying loudly in protest when the mother leaves the room.
Correct Answer: A
Rationale: Drinking from a cup with minimal spilling is advanced for a 7-month-old, who typically lacks such fine motor control.