Nokea
The nurse instructs a mother of a child who had a plaster cast applied to the arm about measures that will help the cast dry. Which instructions should the nurse provide to the mother? Select all that apply.
- A. Lift the cast using the fingertips.
- B. Place the child on a firm mattress.
- C. Direct a fan toward the cast to facilitate drying.
- D. Support the cast and adjacent joints with pillows.
- E. Place the extremity with the cast in a dependent position.
- F. Reposition the extremity with the cast every 2 to 4 hours.
Correct Answer: B,C,D,F
Rationale: To help the cast dry, the child should be placed on a firm mattress. A fan may be directed toward the cast to facilitate drying. Once the cast is dry, the cast should sound hollow and be cool to touch. The cast and adjacent joints should be elevated and supported with pillows. To ensure thorough drying, the extremity with the cast should be repositioned every 2 to 4 hours. The cast is lifted by using the palms of the hands (not the fingertips) to prevent indentation in the wet cast surface. Indentations could possibly cause pressure on the skin under the cast.
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A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which intervention should the nurse implement before administering the antibiotic?
- A. Turn off the TPN for 30 minutes.
- B. Ensure a separate IV access route.
- C. Flush the CVC with normal saline.
- D. Check for compatibility with TPN.
Correct Answer: B
Rationale: The TPN line is used only for the administration of the TPN solution to prevent crystallization in the CVC tubing and disruption of the TPN infusion. Any other IV medication must be administered through a separate IV access site, including a separate infusion port of the CVC catheter. Therefore, options 1, 3, and 4 are incorrect actions.
The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate?
- A. Reassuring the client that those sensations will subside
- B. Discontinuing the enema and notifying the primary health care provider
- C. Raising the enema bag so that the solution can be introduced quickly
- D. Clamping the tubing for 30 seconds and restarting the flow at a slower rate
Correct Answer: D
Rationale: The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The client's report of pain and cramping should not be ignored. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the primary health care provider at this time.
The nurse is caring for a 33-week pregnant client who has experienced a premature rupture of the membranes (PROM). Which interventions should the nurse expect to be part of the plan of care? Select all that apply.
- A. Perform frequent biophysical profiles.
- B. Monitor for elevated serum creatinine.
- C. Monitor for manifestations of infection.
- D. Teach the client how to count fetal movements.
- E. Use strict sterile technique for vaginal examinations.
- F. Inform the client about the need for tocolytic therapy.
Correct Answer: A,C,D,E
Rationale: Premature rupture of membranes (PROM) increases the risk of infection, preterm labor, and fetal compromise. Frequent biophysical profiles assess fetal well-being. Monitoring for manifestations of infection is critical due to the risk of chorioamnionitis. Teaching the client to count fetal movements helps monitor fetal activity and detect potential distress. Strict sterile technique for vaginal examinations minimizes infection risk. Monitoring serum creatinine is not directly related to PROM management. Tocolytic therapy may be considered but is not universally required unless preterm labor is confirmed.
The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take?
- A. Determine the need to increase the oxygen.
- B. Reassure the client that there is no need to worry.
- C. Conduct further assessment of the client's respiratory status.
- D. Call emergency services to take the client to the emergency department.
Correct Answer: C
Rationale: With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is 'no need to worry' is inappropriate. Calling emergency services is a premature action.
The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How should the nurse correctly analyze these results?
- A. The results are positive for active tuberculosis.
- B. The results indicate a less virulent strain of tuberculosis.
- C. The results are inconclusive until a repeat sputum specimen is sent.
- D. The results are unreliable unless the client has also had a positive tuberculin skin test (TST).
Correct Answer: A
Rationale: Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue confirms the diagnosis of active tuberculosis.