Nokea
The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which finding requires priority action?
- A. Blood-tinged stain on the inner aspect of the cast
- B. Capillary refill of 2 seconds on the affected extremity
- C. Mild swelling of toes on the right foot
- D. Pain of 9/10 an hour after a dose of morphine
Correct Answer: D
Rationale: Severe pain (9/10) despite recent morphine suggests complications like compartment syndrome, requiring immediate action. Other findings are less urgent.
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The nurse is caring for a school-aged client recently diagnosed with attention deficit hyperactivity disorder. The nurse should recognize that the client is at risk for experiencing
- A. delayed physical development
- B. delusions
- C. low self-esteem
- D. Paranoia
Correct Answer: C
Rationale: Children with ADHD often face challenges with academic performance and social interactions, increasing the risk of low self-esteem. A is not typically associated with ADHD. B and D are more relevant to psychotic disorders, not ADHD.
An adult asks the nurse about blood types. Which information should the nurse plan to include when replying?
- A. Blood typing is not always accurate.
- B. A person cannot receive a factor that he/she does not have.
- C. The universal donor is AB negative.
- D. A person who is O positive can donate blood to anyone.
Correct Answer: B
Rationale: A person cannot receive blood with antigens (factors) they lack, as it causes an immune reaction. Blood typing is accurate, O negative is the universal donor, and O positive can only donate to Rh-positive types.
The nurse is caring for 4 clients. Which client should the nurse see first?
- A. 2 days post abdominal aortic aneurysm repair with weak pedal pulses and mottled skin on the legs
- B. 2 days post coronary bypass graft surgery with a white blood cell count of 16,000/mm³ (16.0 × 10â¹/L)
- C. Chronic heart failure with peripheral edema and shortness of breath on exertion
- D. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema
Correct Answer: A
Rationale: Weak pulses and mottled skin suggest vascular compromise, a life-threatening complication requiring immediate attention. The other conditions are less urgent.
The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of
- A. Anonymity
- B. Beneficence
- C. Justice
- D. Autonomy
Correct Answer: D
Rationale: Autonomy. Individuals must be free to make independent decisions about participation in research without coercion from others.
Clients taking which of the following drugs are at risk for depression?
- A. Steroids
- B. Diuretics
- C. Folic acid
- D. Aspirin
Correct Answer: A
Rationale: Steroids. Corticosteroids can cause depression as a side effect, which may persist even after discontinuation.