Nokea
The nurse is assessing a client with a cast for compartment syndrome. Which finding is most indicative?
- A. Pain relieved by elevation.
- B. Numbness in the affected limb.
- C. Warm skin over the cast.
- D. Visible swelling at the cast edge.
Correct Answer: B
Rationale: Numbness is a key sign of compartment syndrome, indicating nerve compression requiring urgent intervention.
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The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) has completed an assessment on a client
Item 1 of 1
Nurses' Notes Orders
1923: Assessment completed. Peripheral vascular access device (PAD) was assessed. Erythema
and swelling were noted at the insertion site. The client reported "severe" pain, and
tenderness was endorsed when it was palpated. The infusion was stopped.
The nurse reviews the assessment and is preparing to take action. For each potential action, click to specify whether the potential action is indicated or not indicated for the client.
- A. Remove the peripheral vascular access device
- B. Obtain an order for phentolamine
- C. Notify the physician
- D. Flush the intravenous vascular access device with 5 mL of 0.9% saline (sodium chloride)
- E. Disconnect administration set
Correct Answer: A,C,F
Rationale: Removing the PVAD, notifying the physician, and disconnecting the administration set are indicated for infiltration; flushing is not indicated, and phentolamine is for extravasation.
A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?
- A. Serum potassium is 3.5 mEq/L.
- B. Blood pressure is 88/46.
- C. ST elevation is present on the electrocardiogram.
- D. Heart rate is 61.
Correct Answer: B
Rationale: Nitroglycerin causes vasodilation, which can lower blood pressure. A blood pressure of 88/46 indicates hypotension, a significant concern as it may compromise perfusion, making it the priority assessment.
The nurse is preparing to administer an intradermal injection. Which of the following would be appropriate action by the nurse?
- A. Displace the skin to the side and inject at a 15 degree angle
- B. Position the needle bevel up at 15 degrees
- C. Position the needle bevel up at 45 degrees
- D. Position the needle bevel up at 90 degrees with a dart-like motion
Correct Answer: B
Rationale: Intradermal injections require a 15-degree angle with the bevel up to ensure shallow administration.
A 42-year-old husband and father of a 7-year-old girl and a 10-year-old boy is concerned about what he should tell his children regarding his wife's impending death from aggressive breast cancer. The nurse should:
- A. Refer the family to pastoral care services.
- B. Encourage the husband to come to terms with his own grief first.
- C. Suggest that the children be told nothing until after death occurs.
- D. Begin education about strategies for communication with his children.
Correct Answer: D
Rationale: Educating the husband on communication strategies helps him prepare his children for their mother's death, fostering understanding and emotional support.
Which of the following variables is most important to assess when determining the impact of the cancer diagnosis and treatment modalities on a long-term survivor's quality of life?
- A. Occupation and employability.
- B. Functional status.
- C. Evidence of disease.
- D. Individual values and beliefs.
Correct Answer: B
Rationale: Functional status, including physical and emotional capabilities, is the most important variable affecting a long-term cancer survivor's quality of life, as it reflects their ability to engage in daily activities.