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The nurse is caring for a client who will be taught to ambulate with a cane. Before cane-assisted ambulation instructions begin, what should the nurse check for as the priority to assure client safety?
- A. A high level of stamina and energy
- B. Self-consciousness about using a cane
- C. Full range of motion in lower extremities
- D. Balance, muscle strength, and confidence
Correct Answer: D
Rationale: Assessing the client's balance, strength, and confidence helps determine if the cane is a suitable assistive device for the client. A high level of stamina and full range of motion are not needed for walking with a cane. Although body image (self-consciousness) is a component of the assessment, it is not the priority.
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A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis?
- A. Slowed reflexes
- B. Continuous drooling
- C. Diaphragmatic breathing
- D. Passage of large amounts of frothy stool
Correct Answer: B
Rationale: In esophageal atresia, the esophagus terminates before it reaches the stomach, ending in a blind pouch. This condition prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth and the infant then drools continuously. Responsiveness of the infant to stimulus would depend on the overall condition of the infant and is not considered a classic sign of esophageal atresia. Diaphragmatic breathing is not associated with this disorder. The inability to swallow amniotic fluid in utero prevents the accumulation of normal meconium, and lack of stools results.
A client has just undergone an upper gastrointestinal (GI) series. Upon the client's return to the unit, what primary health care provider's prescriptions does the nurse expect to note as a part of routine postprocedure care?
- A. Bland diet
- B. NPO status
- C. Mild laxative
- D. Decreased fluids
Correct Answer: C
Rationale: Barium sulfate, which is used as a contrast material during an upper GI series, is constipating. If it is not eliminated from the GI tract, it can cause obstruction. Therefore, laxatives or cathartics are administered as part of routine postprocedure care. Increased (not decreased) fluids are also helpful but do not act in the same way as a laxative to eliminate the barium.
A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information should the nurse provide to the client to prevent complications?
- A. Trim the rough edges of the cast after it is dry.
- B. Weight bearing on the right leg is allowed once the cast feels dry.
- C. Expect burning and tingling sensations under the cast for 3 to 4 days.
- D. Keep the right ankle elevated above the heart level with pillows for 24 hours.
Correct Answer: D
Rationale: Leg elevation is important to increase venous return and decrease edema. Edema can cause compartment syndrome, a major complication of fractures and casting. The client and/or family may be taught how to 'petal' the cast to prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in skin integrity. Weight bearing on a fractured extremity is prescribed by the primary health care provider during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately.
The hemoglobin levels of a client in her first trimester of pregnancy are indicative of iron deficiency anemia. Which assessment findings support the diagnosis of this type of anemia? Select all that apply.
- A. Yellowish sclera
- B. Reports of severe fatigue
- C. Pink mucous membranes
- D. Increased vaginal secretions
- E. Reports of frequent headaches
- F. Reports of increased frequency of voiding
Correct Answer: B,E
Rationale: Iron deficiency anemia is described as a hemoglobin blood concentration of less than 10.5 to 11.0 g/dL (105 to 110 mmol/L). Complaints of headaches and severe fatigue are abnormal findings and may reflect complications of this type of anemia caused by the decreased oxygen supply to vital organs. Options 3, 4, and 6 are normal findings in the first trimester of pregnancy. Yellow sclera (whites of the eyes) is associated with jaundice.
An emergency department nurse prepares to plan care for a child diagnosed with acetaminophen overdose. The nurse reviews the primary health care provider's prescriptions and prepares to administer which medication?
- A. Succimer
- B. Vitamin K
- C. Acetylcysteine
- D. Protamine sulfate
Correct Answer: C
Rationale: Acetylcysteine is the antidote for acetaminophen overdose. It is administered orally or via nasogastric tube in a diluted form with water, juice, or soda. It can also be administered intravenously (undiluted). Protamine sulfate is the antidote for heparin. Succimer is used in the treatment of lead poisoning. Vitamin K is the antidote for warfarin.