Nokea
The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?
- A. The nurse assesses capillary refill of 2 seconds
- B. The nurse cannot insert one finger between the cast and the skin
- C. The nurse finds 2+ pulses distal from the cast
- D. The nurse does not observe any drainage
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You may also like to solve these questions
What soft tissue musculoskeletal injury is excessive stretching of a ligament?
- A. Sprain
- B. Ligament tear
- C. Strain
- D. Tendon rupture
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What activities should the client avoid after cataract surgery? (Select all that apply)
- A. Blowing one's nose
- B. Bearing down during defecation
- C. Lifting items heavier than 10 pounds
- D. All of the Above
Correct Answer: D
Rationale: After cataract surgery, the client should avoid activities that can increase intraocular pressure. Blowing one's nose and bearing down during defecation can raise the pressure inside the eye, which can be harmful during the healing process. Lifting items heavier than 10 pounds can also lead to an increase in intraocular pressure. Therefore, all the activities mentioned in the choices (nose blowing, bearing down during defecation, and lifting heavy items) should be avoided after cataract surgery to promote proper healing and reduce the risk of complications.
The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?
- A. Two-point gait
- B. Three-point gait
- C. Four-point gait
- D. Unaffected gait
Correct Answer: B
Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.
The provider orders the client to be placed in a high-Fowler's position. At what angle will the nurse position the client?
- A. 15 degrees
- B. 0 degrees
- C. 90 degrees
- D. 30 degrees
Correct Answer: C
Rationale: The correct answer is C: 90 degrees. In a high-Fowler's position, the client's head of the bed is raised to a 90-degree angle. This positioning helps improve breathing and facilitates eating and talking. Choice A, 15 degrees, is incorrect as it is not high enough to be considered a high-Fowler's position. Choice B, 0 degrees, is incorrect as it represents a flat or supine position. Choice D, 30 degrees, is also incorrect as it does not meet the criteria for a high-Fowler's position.
A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?
- A. The pain will go away after the swelling decreases.
- B. That is phantom limb pain.
- C. Your foot has been amputated, so you are not having pain in that foot.
- D. On a scale of 0-10, how would you rate your pain?
Correct Answer: D
Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.