Nokea
The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician?
- A. Blood pressure of 140/90 mm Hg
- B. Crackles in the lung bases
- C. SUBJECT: Client complains of pain in the affected rib area when taking a deep breath
- D. Heart rate of 94 beats/minute
Correct Answer: B
Rationale: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.
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A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem?
- A. Consult a skin specialist.
- B. Scrub the area vigorously to remove the crust.
- C. Apply lotions and take warm baths or soaks.
- D. Avoid exposure to direct sunlight.
Correct Answer: C
Rationale: The client should be advised to apply lotions and take warm baths or soaks. This will help in softening the skin and removing debris. The client usually sheds this residue in a few days so the client need not consult a skin specialist. It is not advisable to scrub the area vigorously. The client need not avoid exposure to direct sunlight because the area is not photosensitive.
A client having a cast applied for a fractured leg that extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. What type of cast is the client having applied?
- A. Short leg cast
- B. Long leg cast
- C. Walking cast
- D. Hip spica cast
Correct Answer: A
Rationale: A short leg cast extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. A long leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed. A walking cast is a short or long leg cast reinforced for strength. A hip spica cast encloses the trunk and a lower extremity.
The nurse is caring for a client who had a surgical amputation of the left leg related to complication from diabetes. The client asks the nurse: 'If my leg is really gone, then why am I having such bad pain?' What is an appropriate response by the nurse?
- A. You are only imagining that you are having pain.
- B. It is called phantom pain and may come and go.
- C. You will continue to have this pain, and you will have to learn to ignore it.
- D. This is called false pain and is a brain dysfunction.
Correct Answer: B
Rationale: Phantom pain is pain or other discomfort, such as burning, tingling, throbbing, or itching. Pain felt from the phantom limb can be an extremely serious problem in relation to the client's emotional status and ability to use prosthesis. The other responses are nontherapeutic.
A client has a fractured jaw sustained in an automobile accident and has had the fracture surgically reduced and immobilized with a wire loop. What should the nurse ensure is present at the client's bedside in case of vomiting?
- A. Wire cutters
- B. A tracheostomy tray
- C. Ice water with a straw
- D. An antiemetic medication
Correct Answer: A
Rationale: Ensure that wire cutters are easily accessible at the client's bedside. The nurse should be familiar with how to cut wire loops if the client vomits or chokes. A tracheostomy tray is not necessary when an airway can be obtained by cutting the wires so the client does not aspirate. If vomiting occurs, the client should have nothing by mouth. Antiemetic medication should be administered prior to the client vomiting and should not be kept at the bedside.
A client is brought to the emergency department by a softball team member who states the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize?
- A. Client complains of tingling and numbness in the right shoulder.
- B. Right shoulder is elevated above the left.
- C. Client complains of pain in the unaffected shoulder.
- D. Right shoulder slopes downward and droops inward.
Correct Answer: D
Rationale: The client with a fractured clavicle has restricted motion, and the affected shoulder appears to slope downward and droop inward. The client will have pain, not typically tingling and numbness in the right shoulder. Pain is not felt in the unaffected shoulder.