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The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination?
- A. Use a bedside commode.
- B. Ambulate to the bathroom.
- C. Administer an enema daily.
- D. Use a low-profile (fracture) bedpan.
Correct Answer: D
Rationale: A client with a spica cast (body cast) that covers a lower extremity cannot bend at the hips to sit up. A low-profile bedpan or fracture pan is designed for use by clients with body or leg casts and for clients who have difficulty raising the hips to use a standard bedpan; therefore, using a commode or the bathroom is contraindicated. Daily enemas are not a part of routine care.
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The nurse determines that a tuberculin skin test is positive. Which diagnostic test should the nurse anticipate will be prescribed to confirm a diagnosis tuberculosis (TB)?
- A. Chest x-ray
- B. Sputum culture
- C. Complete blood cell count
- D. Computed tomography scan of the chest
Correct Answer: B
Rationale: Although the findings of the chest x-ray examination are important, it is not possible to make a diagnosis of TB solely on the basis of this examination because other diseases can mimic the appearance of TB. The demonstration of tubercle bacilli bacteriologically is essential for establishing a diagnosis. The microscopic examination of sputum for acid-fast bacilli is usually the first bacteriological evidence of the presence of tubercle bacilli. Options 3 and 4 will not diagnose TB.
The nurse is admitting a client who recently underwent a bilateral adrenalectomy. Which intervention is essential for the nurse to include in the client's plan of care?
- A. Prevent social isolation.
- B. Consider occupational therapy.
- C. Discuss changes in body image.
- D. Avoid stress-producing situations.
Correct Answer: D
Rationale: Adrenalectomy can lead to adrenal insufficiency. Adrenal hormones are essential to maintaining homeostasis in response to stressors. None of the remaining options are essential interventions specific to this client's problem.
The nurse is caring for a hospitalized child with a diagnosis of rheumatic fever who has developed carditis. The mother asks the nurse to explain the meaning of carditis. On which description of this complication of rheumatic fever should the nurse base a response?
- A. Involuntary movements affecting the legs, arms, and face
- B. Inflammation of all parts of the heart, primarily the mitral valve
- C. Tender, painful joints, especially in the elbows, knees, ankles, and wrists
- D. Red skin lesions that start as flat or slightly raised macules, usually over the trunk, and that spread peripherally
Correct Answer: B
Rationale: Carditis is the inflammation of all parts of the heart, primarily the mitral valve, and it is a complication of rheumatic fever. Option 1 describes chorea. Option 3 describes polyarthritis. Option 4 describes erythema marginatum.
The nurse is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, which action should the nurse take?
- A. Obtain the newborn infant's blood type and direct Coombs' results from the laboratory.
- B. Obtain the necessary equipment from the blood bank needed for an exchange transfusion.
- C. Call the maintenance department and ask for a phototherapy unit to be brought to the nursery.
- D. Obtain a vial of vitamin K from the pharmacy and prepare to administer an injection to prevent isoimmunization.
Correct Answer: A
Rationale: To further plan for the newborn infant's care, the infant's blood type and direct Coombs' results must be known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn infant. The nurse should obtain these results from the laboratory. Options 2 and 3 are inappropriate at this time, and additional data are needed to determine whether these actions are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease of the newborn infant.
The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action should the nurse plan to implement to decrease the risk of infection in this client?
- A. Track the client's oral temperature.
- B. Administer antibiotics intravenously.
- C. Evaluate the differential of the leukocytes.
- D. Use sterile technique for dressing changes.
Correct Answer: D
Rationale: Sterile technique is vital during dressing changes of a central venous catheter (CVC). CVCs are large-bore catheters that can serve as a direct-entry point for microorganisms into the heart and circulatory system. Using aseptic technique helps avoid catheter-related infections by preventing the introduction of potential pathogens to the site. Although the remaining options are reasonable nursing interventions for a client with a CVC, none of them prevents infection. Options 1 and 3 are assessment methods, and option 2 is implemented after the confirmation of an existing infection.