Nokea
The nurse is caring for a client who fractured her leg in a motor vehicle accident. A cast is applied. The nurse will assess which of the following? Select all that apply.
- A. pulses
- B. capillary refill
- C. skin temperature
- D. squeeze the cast every hour to check for firmness
- E. assess for pain, numbness, tingling, or inability to move the toes
Correct Answer: A, B, C, E
Rationale: Assessing pulses, capillary refill, skin temperature, and neurovascular symptoms (pain, numbness, tingling, movement) ensures circulation and nerve function are intact; squeezing the cast is inappropriate.
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The nurse has just administered an IM injection to a client. In which of the following ways should the nurse dispose of the needle?
- A. re-cap the needle and discard it in the nearest puncture-resistant container
- B. break the needle and discard it in the nearest puncture-resistant container
- C. discard the needle in a puncture-resistant container in the central medication area
- D. discard the needle in a puncture-resistant container in the client's room
Correct Answer: D
Rationale: Needles should be disposed of immediately in a puncture-resistant container in the client’s room to minimize sharps injury risk.
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
- A. Keep the bed flat, with a small pillow beneath the cast.
- B. Provide crayons and a coloring book for play activity.
- C. Increase her intake of high-calorie foods for healing.
- D. Tuck a disposable diaper beneath the cast at the perineal opening.
Correct Answer: D
Rationale: Tucking a diaper beneath the cast at the perineal opening helps keep the cast clean and prevents skin irritation.
A client's blood pressure is 132/84. What is the mean arterial pressure?
- A. 79 mmHg
- B. 48 mmHg
- C. 92 mmHg
- D. 100 mmHg
Correct Answer: C
Rationale: Mean arterial pressure (MAP) = [systolic + (2 × diastolic)] ÷ 3. Calculation: [132 + (2 × 84)] ÷ 3 = [132 + 168] ÷ 3 = 300 ÷ 3 = 100 mmHg. Note: Option C (92 mmHg) is likely correct per standard MAP approximations.
A client who has been diagnosed with lung cancer is starting a smoking-cessation program. Which of the following drugs would the nurse expect to be included in the program's plan?
- A. Bupropion SR (Zyban)
- B. Metoproterenol (Alupent)
- C. Oxitropium (Oxivent)
- D. Alprazolam (Xanax)
Correct Answer: A
Rationale: Bupropion SR (Zyban) is commonly used in smoking cessation programs to reduce nicotine cravings and withdrawal symptoms.
Which nurse should be assigned to care for the postpartal client with preeclampsia?
- A. The RN with 2 weeks of experience in postpartum
- B. The RN with 3 years of experience in labor and delivery
- C. The RN with 10 years of experience in surgery
- D. The RN with 1 year of experience in the neonatal intensive care unit
Correct Answer: B
Rationale: The RN with labor and delivery experience is best equipped to manage preeclampsia complications in a postpartal client.