Nokea
The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety?
- A. Monitoring for heel breakdown
- B. Monitoring for bladder distention
- C. Monitoring for extremity shortening
- D. Monitoring for blanching ability of toe nail beds
Correct Answer: D
Rationale: With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although heel breakdown, bladder distention, or extremity lengthening or shortening can occur, these complications are not potentially life-threatening complications.
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The nurse is encouraging the client to cough and deep breathe after cardiac surgery. The nurse ensures that which item is available to maximize the effectiveness of this procedure?
- A. Nebulizer
- B. Ambu bag
- C. Suction equipment
- D. Incisional splinting pillow
Correct Answer: D
Rationale: The use of an incisional splint such as a 'cough pillow' can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options 1, 2, and 3 will not encourage the client to cough and deep breathe.
The nurse caring for a child admitted to the hospital with a diagnosis of viral pneumonia describes the treatment plan to the parents. The nurse determines the need for further teaching when the parents make which statement regarding the treatment?
- A. We need to be very careful since oxygen is extremely flammable.
- B. It's important that the child isn't allergic to the antibiotic that is prescribed.
- C. It's difficult to watch the needle be inserted when intravenous fluids are needed.
- D. Chest physiotherapy will loosen the congestion, so coughing will clear the lungs.
Correct Answer: B
Rationale: The therapeutic management for viral pneumonia is supportive. Antibiotics are not given unless the pneumonia is bacterial. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and intravenous fluids.
The nurse evaluates a client after treatment for carbon monoxide poisoning following a burn injury. The nurse should document that the treatment was effective if which finding was present? Select all that apply.
- A. The client is sleeping soundly.
- B. The client is awake and talking.
- C. Respiratory rate is 26 breaths/minute.
- D. The client's heart rate is 84 beats/minute.
- E. Carboxyhemoglobin levels are less than 5%.
- F. The heart monitor shows normal sinus rhythm.
Correct Answer: D,E,F
Rationale: Normal carboxyhemoglobin levels are less than 5% for a nonsmoking adult. Clients can be awake and talking with abnormally high levels. The symptoms of carbon monoxide poisoning are tachycardia, tachypnea, and central nervous system depression.
A client diagnosed with diabetes mellitus is at 36 weeks' gestation. The client has had weekly reactive nonstress tests for the last 3 weeks. This week, the nonstress test was nonreactive after 40 minutes. Based on these results, the nurse should prepare the client for which intervention?
- A. A contraction stress test
- B. Immediate induction of labor
- C. Hospitalization with continuous fetal monitoring
- D. A return appointment in 2 days to repeat the nonstress test
Correct Answer: A
Rationale: A nonreactive nonstress test after 40 minutes indicates that the fetus did not show the expected heart rate accelerations, which may suggest fetal compromise, particularly in a high-risk pregnancy such as one with diabetes mellitus. The next step is typically a contraction stress test to further assess fetal well-being by evaluating the fetal heart rate response to uterine contractions. Immediate induction or hospitalization may be premature without further evaluation, and repeating the nonstress test in 2 days delays necessary assessment.
A client has a total serum calcium level of 7.5 mg/dL (1.88 mmol/L). Which clinical manifestations should the nurse expect to note on assessment of the client? Select all that apply.
- A. Constipation
- B. Muscle twitches
- C. Negative Chvostek's sign
- D. Positive Trousseau's sign
- E. Hyperactive deep tendon reflexes
- F. Prolonged ST interval on electrocardiogram (ECG)
Correct Answer: B,D,E,F
Rationale: Hypocalcemia is a total serum calcium level less than 9 mg/dL (2.25 mmol/L). Clinical manifestations include muscle twitches, hyperactive deep tendon reflexes, positive Trousseau's sign, and prolonged ST interval on ECG. Negative Chvostek's sign and constipation are not associated with hypocalcemia.