Nokea
The nurse in the outpatient clinic is talking with a client who sustained a distal fracture of the humerus and had a cast applied 2 days ago. Which of the following statements by the client would be a priority to follow up?
- A. I am able to insert one finger between my cast and arm.
- B. I use a nail file to scratch my skin under the cast when it itches.
- C. I am having difficulty extending my fingers since I woke up this morning.
- D. I cannot take the prescribed pain medication because it makes me nauseous.
Correct Answer: C
Rationale: Difficulty extending fingers suggests nerve compression or compartment syndrome, a priority for follow-up. Other statements are less urgent.
You may also like to solve these questions
The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse?
- A. Chewable aspirin is the preferred analgesic
- B. Topical cortisone ointment relieves itching
- C. Supples, vesicles, and crusts will be present at one time
- D. The illness is only contagious prior to lesion eruption
Correct Answer: C
Rationale: Supples, vesicles, and crusts will be present at one time. Chickenpox lesions appear in multiple stages simultaneously.
The nurse is working to prevent falls in a restraint-free environment. Which of the following is inappropriate for the nurse to delegate to assistive personnel?
- A. Making sure the bed is in low position
- B. Making sure the bedside table is within reach of the client
- C. Assessing the safety needs of the client
- D. Monitoring client behavior for potential falls
Correct Answer: C
Rationale: Assessing safety needs requires nursing judgment, inappropriate for delegation to assistive personnel, unlike routine tasks like bed positioning.
While caring for a client with a pulmonary embolus, the nurse notes several petechiae on his chest and abdomen. Which action should the nurse take first?
- A. Apply ice packs to the area.
- B. Record the finding in the client's chart.
- C. Report the finding to the physician.
- D. Monitor the finding.
Correct Answer: C
Rationale: Petechiae may indicate a coagulopathy or emboli-related complication, requiring prompt reporting to the physician for further evaluation. Recording and monitoring are secondary, and ice packs are inappropriate.
An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately?
- A. Is there anything I can take for my dry, hacking cough?
- B. My blood pressure this morning was 158/84 mm Hg.
- C. Sometimes I feel a little dizzy when I stand up.
- D. Will you look at my tongue? It feels thicker than normal.
Correct Answer: D
Rationale: A thicker tongue may indicate angioedema, a rare but life-threatening side effect of enalapril (an ACE inhibitor), requiring immediate reporting. A (dry cough) and C (dizziness) are common side effects that warrant monitoring but are less urgent. B indicates suboptimal blood pressure control, which requires follow-up but is not immediately life-threatening.
The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
- A. Phlebostatic axis
- B. Point of maximum impulse (PMI)
- C. Erb's point
- D. Tail of Spence
Correct Answer: A
Rationale: The phlebostatic axis is the reference point for accurate central venous pressure measurement, as it corresponds to the right atrium's level. The point of maximum impulse, Erb's point, and Tail of Spence are not used for this purpose, so answers B, C, and D are incorrect.