Nokea
The nurse is caring for a client who has a hip fracture and is placed in Buck traction. Which of the following actions should the nurse take? Select all that apply.
- A. Place the client on the affected side.
- B. Monitor the client for skin breakdown.
- C. Perform frequent neurovascular checks.
- D. Keep the affected extremity in a neutral position.
- E. Ensure that the client receives adequate pain relief.
Correct Answer: B,C,D,E
Rationale: Monitoring for skin breakdown (B), neurovascular checks (C), neutral positioning (D), and pain relief (E) are essential for Buck traction. Placing the client on the affected side (A) is incorrect as it may disrupt traction.
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The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?
- A. Complaints of numbness and tingling in feet
- B. Wheezing noted when lung sounds auscultated
- C. Excessive perspiration
- D. Difficulty sleeping
Correct Answer: A
Rationale: Complaints of numbness and tingling in feet. A child who has unusual neurologic signs or symptoms, neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.
While admitting a client to an acute-care psychiatric unit, the nurse asks about substance abuse based on knowledge that:
- A. psychiatric illness is more prevalent in addicted populations.
- B. people with psychiatric disorders are more prone to substance abuse.
- C. substance disorders are easily detected and diagnosed in acute-care psychiatric settings.
- D. undetected substance problems have no real effect on treatment of psychiatric disorders.
Correct Answer: B
Rationale: The failure to address substance abuse among clients with psychiatric disorders interferes with treatment effectiveness and contributes to relapse. Misdiagnosis of a psychiatric disorder, suboptimal pharmacological treatment, neglect of appropriate interventions, or an inappropriate referral might also occur.
The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Attaches an 18-gauge injection needle to a syringe for withdrawal of medication
- B. Breaks the ampule neck away from the nurse's body to prevent injury from the glass
- C. Disposes of the empty glass ampule in a sharps container
- D. Injects air into the glass ampule prior to withdrawing the medication
- E. Rests and steadies the needle on the ampule's outer rim to withdraw medication
Correct Answer: B,C
Rationale: Breaking the ampule away from the body (B) and disposing in a sharps container (C) are safe practices. An 18-gauge needle (A) is too large, injecting air (D) is unnecessary, and resting the needle on the rim (E) risks contamination.
While assisting a client with AM care, the nurse notes small elevated skin lesions less than $0.5 \mathrm{cm}$ in diameter over the client's back. The nurse should describe the lesions as:
- A. Macules
- B. Plaques
- C. Wheals
- D. Papules
Correct Answer: D
Rationale: Papules are small, elevated skin lesions less than 0.5 cm in diameter, matching the description provided.
The client is admitted for a bronchoscopy this morning. Which question is essential for the nurse to ask the client?
- A. When did you last eat?'
- B. Did you take the laxative as ordered?'
- C. What has the doctor told you about your procedure?'
- D. Have you had conscious sedation before?'
Correct Answer: A
Rationale: Bronchoscopy requires NPO status to prevent aspiration; confirming last intake is essential. Laxatives, procedure knowledge, or sedation history are secondary.