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The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
- A. Weak pedal pulses
- B. Drainage at the pin sites
- C. Complaints of leg discomfort
- D. Toes demonstrating a brisk capillary refill
Correct Answer: A
Rationale: Buck's traction is skin traction. Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. Skeletal (not skin) traction uses pins. Discomfort is expected. Warm toes with brisk capillary refill is a normal finding.
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The nurse is caring for a client diagnosed with active tuberculosis who is prescribed rifampin therapy. The nurse instructs the client to expect which side effect of this medication?
- A. Green urine
- B. Yellow sclera
- C. Orange secretions
- D. Clay-colored stools
Correct Answer: C
Rationale: Rifampin is an antituberculosis medication. Secretions will become orange in color as a result of the rifampin. The client should be instructed that this side effect will likely occur.
A client diagnosed with acute pyelonephritis is scheduled for an intravenous pyelogram this morning. During report the nurse learns that the client vomited several times during the night and continues to report being nauseated. What intervention should the nurse implement to assure the client's safety regarding the scheduled procedure?
- A. Cancels the pyelogram
- B. Monitors the client closely for any additional vomiting
- C. Medicates the client with a standing order for metoclopramide
- D. Requests a prescription for a 0.9% saline intravenous infusion
Correct Answer: D
Rationale: The highest priority of the nurse would be to request a prescription for an intravenous infusion. This is needed to replace fluid lost with vomiting, will be necessary for dye injection for the procedure, and will assist with the elimination of the dye after the procedure. The cancelation of the procedure is premature. Neither monitoring nor medicating the patient with an antiemetic will address the fluid loss problem.
The nurse has a prescription to administer amphotericin B intravenously to the client diagnosed with histoplasmosis. Which should the nurse specifically plan to implement during administration of the medication to minimize the client's risk for injury? Select all that apply.
- A. Monitor for hyperthermia.
- B. Monitor for an excessive urine output.
- C. Administer a concurrent fluid challenge.
- D. Assess the intravenous (IV) infusion site.
- E. Assess the chest and back for a red, itchy rash.
- F. Monitor the client's orientation to time, place, and person.
Correct Answer: A,D
Rationale: Amphotericin B is an antifungal medication and is a toxic medication, which can produce symptoms during administration such as chills, fever (hyperthermia), headache, vomiting, and impaired renal function (decreased urine output). The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications. Administering a concurrent fluid challenge is not necessary. A rash or disorientation is not specific to this medication.
An echocardiogram, chest x-ray (CXR), and computed axial tomography (CAT) scan are prescribed for a client who has activity intolerance. In which order should the nurse plan to schedule the procedures to meet the needs of this client safely and effectively?
- A. CAT scan and CXR in the morning, and echocardiogram on the following morning
- B. CXR and echocardiogram together in the morning, and CAT scan in the afternoon of the same day
- C. Echocardiogram in the morning, and CXR and CAT scans together in the afternoon of the same day
- D. CXR in the morning, echocardiogram in the afternoon, and CAT scan in the morning of the following day
Correct Answer: D
Rationale: CAT scans are always performed in radiology, and CXR and echocardiograms can be done at the bedside; however, the best results usually occur when the test is performed in the related department. As long as the client is stable and transportation is provided, the nurse can schedule each procedure in its department with two procedures on the first day separated by a rest period, and the remaining procedure the next day.
The nurse in the mental health unit is preparing to admit a severely depressed client. Which findings on assessment support the diagnosis of this client? Select all that apply.
- A. Insomnia
- B. Flat affect
- C. Hypersomnia
- D. Substantial weight loss
- E. Weight gain since onset of depression
- F. Reports, 'I don't have any more tears to cry.'
Correct Answer: A,B,D,F
Rationale: In the severely depressed client, loss of weight is typical, whereas the mildly depressed client may experience a gain in weight. Sleep is generally affected in a similar way, with hypersomnia in the mildly depressed client and insomnia in the severely depressed client. The severely depressed client may report that no tears are left for crying. A flat affect may be associated with depression.