Nokea
The nurse is caring for a 5 year-old child whose left leg is in skeletal traction. Which of the following activities would be an appropriate diversional activity?
- A. Kicking balloons with right leg
- B. Playing 'Simon Says'
- C. Playing hand held games
- D. Throw bean bags
Correct Answer: C
Rationale: Playing hand held games. Immobilization with traction must be maintained until bone ends are in satisfactory alignment. Activities that increase mobility interfere with the goals of treatment.
You may also like to solve these questions
Laboratory reference ranges
Sodium
136-145 mEq/L
(136-145 mmol/L)
Potassium
3.5-5 mEq/L
(3.5-5 mmol/L)
Creatinine
Male: 0.6–1.3 mg/dL
(53.0–114.9 μmol/L)
Female: 0.5-1.1 mg/dL
(44.2-97.2 μmol/L)
BUN
10-20 mg/dL
(3.6-7.1 mmol/L)
The nurse has been made aware of laboratory test results for a client who is receiving continuous cardiac monitoring. The client is asymptomatic, and the cardiac monitor shows normal sinus rhythm. Which of the following is most likely an erroneous test result?
- A. BUN of 60 mg/dL (21.4 mmol/L)
- B. serum sodium level of 155 mEq/L (155 mmol/L)
- C. serum potassium level of 7.0 mEq/L (7.0 mmol/L)
- D. serum creatinine level of 4.0 mg/dL (353.6 μmol/L)
Correct Answer: C
Rationale: A potassium level of 7.0 mEq/L (C) is life-threatening and would likely cause arrhythmias, inconsistent with normal sinus rhythm and asymptomatic status, suggesting an error. Elevated BUN (A), sodium (B), and creatinine (D) are concerning but plausible in renal or dehydration issues without immediate cardiac effects.
The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse?
- A. Ambulates through the hallway several times per day
- B. Applies a warm compress to the site of inflammation
- C. Elevates the limb above the level of the heart while in bed
- D. Massages the affected leg to reduce pain and swelling
Correct Answer: D
Rationale: Massaging the leg (D) risks dislodging the clot, causing embolism, requiring immediate intervention. Ambulation (A), warm compresses (B), and elevation (C) are appropriate.
The physician has ordered dressings with sulfamylon cream for a client with full thickness burns of his hands and arms. Before dressing changes, the nurse should give priority to:
- A. Administering pain medication
- B. Checking the adequacy of urinary output
- C. Requesting a daily complete blood count
- D. Obtaining a blood glucose by finger stick
Correct Answer: A
Rationale: Sulfamylon dressing changes are painful, so administering pain medication is the priority. Urinary output , blood count , and glucose are important but secondary.
The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
- A. Canned baby food is more expensive than food prepared at home
- B. Finger foods can be introduced before the child has teeth
- C. New foods should be introduced at least 5-7 days apart
- D. Rice cereal can be mixed with cow's milk to increase nutritional intake
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (C) prevents allergic reactions by identifying triggers, making it the priority. Cost (A), finger foods (B), and cow's milk (D, not recommended before 12 months) are secondary.
What is the most important aspect to include when developing a home care plan for a client with severe arthritis?
- A. Maintaining and preserving function
- B. Anticipating side effects of therapy
- C. Supporting coping with limitations
- D. Ensuring compliance with medications
Correct Answer: A
Rationale: Maintaining and preserving function. Preserving joint function is critical for quality of life in arthritis.