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 family of an 88-year-old woman who was admitted with severe dehydration says to the nurse, 'Why don't you just tie down her arms so she won't try to get out her IV?' What is the best response for the nurse to make?
- A. Ask the physician for an order to restrain the woman
- B. Explain to the family that restraints are not allowed in the hospital unless the doctor orders them
- C. Assess the client's mental status and safety needs
- D. Tell the family that they can restrain the client, but the nurse cannot
Correct Answer: C
Rationale: Assessing mental status and safety needs determines if restraints are necessary, prioritizing least restrictive measures.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone. Which of the following actions should the nurse take? Select all that apply.
- A. Administer vasopressin.
- B. Implement seizure precautions.
- C. Perform frequent neurological checks.
- D. Keep a strict record of fluid intake and output.
- E. Maintain an IV infusion of 0.9% sodium chloride.
Correct Answer: B,C,D
Rationale: Seizure precautions (B), neurological checks (C), and strict I&O (D) manage SIADH complications like hyponatremia. Vasopressin (A) worsens SIADH, and normal saline (E) may not correct hyponatremia.
A charge nurse working in a long term care facility is making out assignments. Which assignment made by a registered nurse to an unlicensed assistive personnel (UAP) requires intervention by the supervisor?
- A. Provide decubitus ulcer care and apply a dry dressing
- B. Bathe and feed a client on bed rest
- C. Oral suctioning of an unresponsive elderly client
- D. Teaching a family intermittent (bolus) feedings via G-tube before discharge
Correct Answer: D
Rationale: Teaching a family intermittent (bolus) feedings via G-tube before discharge. Initial teaching cannot be delegated to a UAP or a PN and must be done by RNs.
The nurse is assessing a 7-year-old client who was recently admitted with nausea, vomiting, severe right lower quadrant pain, and an elevated WBC count. Which of the following statements by the client would be a priority to follow up?
- A. I feel so tired.
- B. I am hungry and I want to eat.
- C. My stomach does not hurt anymore.
- D. I do not like hospitals and I want to go home.
Correct Answer: C
Rationale: Resolution of pain (C) in suspected appendicitis may indicate perforation, a surgical emergency, requiring urgent follow-up. Fatigue (A), hunger (B), and dislike of hospitals (D) are less critical.
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
- A. Offer the baby sterile water between feedings of formula
- B. Apply an emollient to the baby's skin to prevent drying
- C. Wear a gown, gloves, and a mask while caring for the infant
- D. Place the baby on enteric isolation
Correct Answer: B
Rationale: Applying an emollient prevents skin drying, a common issue during phototherapy due to exposure to light.