Nokea
The nurse is assessing a client with suspected appendicitis.
- A. Which finding supports a diagnosis of appendicitis in a client with right lower quadrant pain?
- B. Pain relieved by lying in a supine position.
- C. Positive rebound tenderness at McBurney’s point.
- D. Absence of bowel sounds on auscultation.
- E. A white blood cell count of 8,000/mm³.
Correct Answer: B
Rationale: Positive rebound tenderness at McBurney’s point is a hallmark of appendicitis, indicating peritoneal irritation. Supine positioning may worsen pain, absent bowel sounds suggest obstruction, and a normal WBC count does not rule out appendicitis.
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A client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting.
It is MOST important for the nurse to
- A. assess drainage from Penrose drains.
- B. observe dressings for signs of excessive bleeding.
- C. elevate the stump for no less than 40 hours.
- D. provide cast care to the affected extremity.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of each implementation. (1) drains not usually used with amputations (2) rigid cast dressing frequently used to create a socket for prosthesis (3) elevation of extremity unnecessary, rigid cast dressing prevents swelling (4) correct-cast applied to provide uniform compression, prevent pain and contractures
A 10-year-old for a cardiac catheterization.
Which of the following plans would be MOST appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization?
- A. Show a videotape specifically prepared for children about cardiac catheterization.
- B. Provide the child with a pamphlet about the procedure and encourage him to read it.
- C. Draw a picture of a heart and explain where the tube will go and what the doctor will see.
- D. Present a puppet show explaining the anatomy and physiology of the heart.
Correct Answer: C
Rationale: Strategy: Think about the developmental stage of a 10-year-old. (1) video will provide correct information but is not best preparation for a school-age child (2) pamphlet will contain correct information but is not best preparation for a school-age child (3) correct-this plan will best prepare the child for the procedure (4) would be more appropriate for a younger child
The nurse is caring for a client with an electrical burn. Which structures have the greatest risk for soft tissue injury?
- A. Fat, tendons, and bones
- B. Skin and hair
- C. Nerves, muscle, and blood vessels
- D. Skin, fat, and muscle
Correct Answer: A
Rationale: Fat, tendon, and bone have the most resistance. The higher the resistance, the greater the heat generated by the current, thereby increasing the risk for soft tissue injury. Answer B has intermediate resistance, so it is incorrect. Answer C is incorrect because it has very low resistance. Answer D has low to intermediate resistance, so it is incorrect.
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment.
- A. What should the nurse do if the patient’s left leg is externally rotated?
- B. Place a trochanter roll on the outer aspect of the thigh.
- C. Perform resistive range of motion of the left leg.
- D. Adduct and internally rotate the left leg.
- E. Instruct the patient to maintain the left leg in a neutral position.
Correct Answer: A
Rationale: A trochanter roll placed on the outer aspect of the thigh prevents external rotation by holding the hip in a neutral position and maintaining normal leg alignment. Resistive exercises, manual repositioning, or instructing the patient to maintain position are less effective, as they do not provide sustained support to prevent rotation.
The nurse has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. A patient who had coronary artery bypass graft (CABG) and will have the atrioventricular (AV) wires removed later in the day.
- B. A patient with type I diabetes who is scheduled for a cardiac catheterization later today.
- C. A patient who is one-day postoperative and has an epidural catheter in place.
- D. A patient who is being evaluated for a heart transplant.
Correct Answer: C
Rationale: Strategy: Determine which patient is the least stable. (1) although the patient requires a high level of nursing care, no indication that the patient is unstable (2) patient requires preoperative assessment and teaching, no indication that the patient is unstable (3) correct-epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting (4) requires monitoring but patient with epidural takes priority