Nokea
The nurse is caring for a client in skeletal traction for a femoral fracture. Which assessment should be prioritized?
- A. Skin integrity at pin sites.
- B. Room temperature control.
- C. Frequency of bowel movements.
- D. Client's emotional status.
Correct Answer: A
Rationale: Pin site infections are a common complication in skeletal traction, requiring prioritized assessment.
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What is the priority nursing action for a client with a suspected brain tumor?
- A. Administer pain medication.
- B. Monitor neurological status.
- C. Provide emotional support.
- D. Restrict physical activity.
Correct Answer: B
Rationale: Monitoring neurological status is the priority to detect changes associated with a brain tumor.
A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given I.V. The nurse should first:
- A. Administer the morphine.
- B. Obtain a 12-lead ECG.
- C. Obtain the blood work.
- D. Order the chest radiograph.
Correct Answer: A
Rationale: Administering morphine first relieves pain, reducing myocardial oxygen demand and stabilizing the client. ECG and blood work follow to confirm diagnosis, but pain management is the priority.
A client with detachment of the retina is to patch both eyes. The expected outcome of patching is to:
- A. Reduce rapid eye movements.
- B. Decrease the irritation caused by light entering the damaged eye.
- C. Protect the injured eye from infection.
- D. Rest the eyes to promote healing.
Correct Answer: A
Rationale: Patching both eyes reduces rapid eye movements, which could worsen retinal detachment by preventing further stress on the retina.
Which assessment is most important for a client with a traumatic brain injury?
- A. Glasgow Coma Scale.
- B. Blood glucose levels.
- C. Electrolyte panel.
- D. Pain assessment.
Correct Answer: A
Rationale: The Glasgow Coma Scale is critical to assess neurological status and guide management in traumatic brain injury.
The nurse is preparing to administer an intramuscular (IM) injection into the client's vastus lateralis. The nurse is correct in identifying the landmark by
- A. palpating to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third.
- B. locating the acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion.
- C. locating the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers.
- D. displacing the skin by pulling the skin down or to one side about 1 inch with the non-dominant hand before administering the injection.
Correct Answer: A
Rationale: The vastus lateralis is correctly located by dividing the thigh into thirds between the greater trochanter and knee, with the middle third being the injection site.