Nokea
The nurse is assessing a client with a lower leg cast who has just been measured and fitted for crutches. Which observation should help the nurse determine if the client's crutches are fitted correctly?
- A. The top of the crutch is even with the axilla.
- B. The elbow is straight when the hand is on the handgrip.
- C. The client's axilla is resting on the crutch pad during ambulation.
- D. The elbow is at a 30-degree angle when the hand is on the handgrip.
Correct Answer: D
Rationale: When using crutches, for optimal upper extremity leverage, the elbow should be at approximately 30 degrees of flexion when the hand is resting on the handgrip. The top of the crutch needs to be two to three finger widths lower than the axilla. When crutch walking, all weight needs to be on the hands to prevent nerve palsy from pressure on the axilla. Therefore, options 1, 2, and 3 are incorrect.
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A client receiving chemotherapy has an extremely low white blood cell count and is immediately placed on neutropenic precautions that include a low-bacteria diet. Which food items is the client now allowed to consume? Select all that apply.
- A. Raw celery
- B. Fresh apple
- C. Italian bread
- D. Tossed salad
- E. Baked chicken
- F. Well-cooked cheeseburger
Correct Answer: C,E,F
Rationale: An extremely low white blood cell count places the client at risk for infection. In the immunocompromised client, a low-bacteria diet is implemented. Italian bread, baked chicken, and a well-done cheeseburger are acceptable to consume because all products are thoroughly cooked. The client avoids eating fresh fruits and vegetables. Fresh fruits and vegetables harbor organisms and place the client at risk for infection.
A client is being admitted to the hospital after receiving a radiation implant after being diagnosed with cervical cancer. Which priority action should the nurse implement in the care of this client?
- A. Encourage the family to visit.
- B. Admit the client to a private room.
- C. Place the client on protective isolation.
- D. Encourage the client to take frequent rest periods.
Correct Answer: B
Rationale: The client who has a radiation implant is placed in a private room and has limited visitors. This reduces the exposure of others to the radiation. Protective isolation is unnecessary; rather, individuals other than the client need to be protected. Frequent rest periods are a helpful general intervention but are not a priority for the client in this situation.
The registered nurse instructs the new nurse that a variance analysis is performed on all clients with respect to which time frame?
- A. Continuously
- B. Daily during hospitalization
- C. Every third day of hospitalization
- D. Every other day of hospitalization
Correct Answer: A
Rationale: Variance analysis occurs continually as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical paths is to anticipate and recognize negative variance early so that appropriate action can be taken. A negative variance occurs when untoward events preclude a timely discharge and the length of stay is longer than planned for a client on a specific critical path. Options 2, 3, and 4 are incorrect.
The nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency department. Using principles of triage, the nurse should implement immediate care for a client with which injury?
- A. Fractured tibia
- B. Penetrating abdominal injury
- C. Bright red bleeding from a neck wound
- D. Open massive head injury, resulting in deep coma
Correct Answer: C
Rationale: The client with bright red (arterial) bleeding from a neck wound is in 'immediate' need of treatment to save the client's life. This client is classified as an emergent (life-threatening) client and would wear a color tag of red from the triage process. A green or 'minimal' (nonurgent) designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. The client with a penetrating abdominal injury would be tagged yellow and classified as 'urgent,' requiring intervention within 60 to 120 minutes. A designation of 'expectant' would be applied to the client with massive injuries and minimal chance of survival. This client would be color-coded 'black' in the triage process. The client who is color-coded 'black' is given supportive care and pain management but is given definitive treatment last.
The nurse is assisting with the transfer of a client from the operating room table to a stretcher. Which interventions should the nurse implement to ensure client safety? Select all that apply.
- A. Check the client's level of consciousness.
- B. Check wheel locks of the operating room table.
- C. Complete the client transfer as quickly as possible.
- D. Tell the client to move self from the table to the stretcher.
- E. Raise side rails after the client is positioned on the stretcher per agency policy.
Correct Answer: A,B,E
Rationale: As part of the safe transfer of a client after a surgical procedure, the nurse should assess the client's level of consciousness and, if appropriate, let the client know that she or he will be transferred from the operating room table to the stretcher. The nurse checks the wheel locks of the table and the stretcher to prevent any movement during the transfer. In addition, the nurse raises the side rails per agency policy to prevent the client from falling off the stretcher. This is important because the client is likely to be sedated or disoriented and unable to protect herself or himself from falling. Personnel avoid hurried movements and rapid changes in position because hurried movements predispose the client to hypotension; moreover, secure, deliberate movement increases the security of the client. Because the client remains affected by anesthesia, the client should not move herself or himself.