Nokea
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg
- B. Cover the bone area with a sterile dressing
- C. Apply an ACE bandage around the entire lower limb
- D. Place the client in the prone position
Correct Answer: B
Rationale: An open fracture with protruding bone risks infection. Covering with a sterile dressing is the priority to prevent contamination. Traction or bandaging may worsen the injury.
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A client has returned from surgery after removal of a tumor of the colon and creation of a temporary colostomy. She refuses to take a deep breath and cough then refuses to turn. Which of the following should the nurse assess first in trying to understand her lack of cooperation?
- A. Delirium status.
- B. Vital signs.
- C. Oxygen saturation.
- D. Level of pain.
Correct Answer: D
Rationale: Pain (D) is the most likely reason for refusing to cough or turn post-surgery, as these actions can exacerbate discomfort. Assessing pain first guides appropriate interventions. Delirium (A), vital signs (B), and oxygen saturation (C) are secondary.
A client has been receiving Rheumatrex (methotrexate) for severe rheumatoid arthritis. The nurse should tell the client to avoid taking:
- A. Aspirin
- B. Multivitamins
- C. Omega 3 fish oils
- D. Acetaminophen
Correct Answer: A
Rationale: Aspirin can increase methotrexate toxicity by reducing its renal excretion, leading to potentially severe side effects.
The nurse has performed discharge teaching to a client in need of a high-iron diet. The nurse recognizes that teaching has been effective when the client selects which meal plan?
- A. Hamburger, French fries, and orange juice
- B. Sliced veal, spinach salad, and whole-wheat roll
- C. Vegetable lasagna, Caesar salad, and toast
- D. Bacon, lettuce, and tomato sandwich; potato chips; and tea
Correct Answer: B
Rationale: Veal and spinach are high in iron, and whole-wheat roll provides additional nutrients. The other meals lack significant iron sources.
The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:
- A. Rotating application sites
- B. Limiting applications to the chest
- C. Rubbing it into the skin
- D. Covering it with a gauze dressing
Correct Answer: A
Rationale: Rotating sites prevents skin irritation and ensures consistent absorption.
The client delivered a 9-pound infant two days ago. An effective means of managing discomfort from an episiotomy is:
- A. Medicated suppository
- B. Taking showers
- C. Sitz baths
- D. Ice packs
Correct Answer: C
Rationale: Sitz baths relieve episiotomy pain by promoting circulation and healing.