Nokea
The nurse is caring for a client after an open reduction to the left ulna. The client's left arm is in a plaster cast with an Ace wrap for reinforcement. Which intervention by the nurse can offer nonpharmacological comfort to this client?
- A. elevate the left arm on a pillow and apply an ice pack over the approximate location of the surgical incision
- B. call the physician and obtain an order for acetaminophen (Tylenol) 650 mg PO PRN q6 hours as needed for pain
- C. advise the client that if he starts to itch under the cast, he can use a wire coat hanger or an ink pen to gently scratch up under the cast
- D. perform range-of-motion exercises twice a shift, including bending the fingers, opening and closing the hand, and lifting the arm up to shoulder level
Correct Answer: A
Rationale: Elevation and ice reduce swelling and pain nonpharmacologically. Scratching under the cast risks skin damage, and excessive movement may disrupt healing.
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A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
- A. Anticipate the need for a Caesarean section
- B. Apply an internal fetal monitor
- C. Place the client in Genu Pectoral position
- D. Perform an ultrasound
Correct Answer: A
Rationale: Footling breech presentation often requires a Caesarean section due to risks of cord prolapse and delivery complications.
The nurse is working with a nursing student to administer an enema solution to a client. The client states she feels painful cramping. The nurse should intervene by
- A. squeezing the enema bag so the flow rate is faster.
- B. explaining to the client that this is a normal feeling and continuing with the enema.
- C. clamping the tube for 1 minute and then starting the enema at a slower rate.
- D. discontinuing the enema until the provider can order a PRN pain medication.
Correct Answer: C
Rationale: Painful cramping during an enema suggests too-rapid administration. Clamping briefly and slowing the rate reduces discomfort.
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by:
- A. Passing water through a dialyzing membrane
- B. Eliminating plasma proteins from the blood
- C. Lowering the pH by removing nonvolatile acids
- D. Filtering waste through a dialyzing membrane
Correct Answer: D
Rationale: Hemodialysis filters waste products and excess fluids through a dialyzing membrane, mimicking kidney function.
A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler's position, the nurse's next action should be to:
- A. Notify the physician
- B. Make sure the catheter is patent
- C. Administer an antihypertensive
- D. Provide supplemental oxygen
Correct Answer: B
Rationale: Autonomic hyperreflexia is often triggered by bladder distension; ensuring a patent catheter addresses the most common cause and can resolve symptoms.
A nurse has received report on the day's clients. In planning morning rounds, which client is the priority to see?
- A. a new admission with a UTI and fever
- B. a client who is NPO for surgery later in the morning
- C. a client complaining of nausea after eating breakfast
- D. a client recently complaining of shortness of breath
Correct Answer: D
Rationale: Shortness of breath indicates a potential respiratory or cardiac issue, making this client the priority for immediate assessment.