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The nurse is caring for a client with a closed reduction of a fractured femur. Following the reduction, the nurse should check the client's affected extremity every 15-30 minutes for:
- A. Warmth and redness
- B. Color and pulses
- C. Pain and swelling
- D. Alignment and position
Correct Answer: B
Rationale: Checking color and pulses every 15-30 minutes post-reduction detects circulatory compromise in a fractured femur warmth, pain, or alignment are secondary. Nurses assess distal perfusion, reporting pallor or pulselessness, preventing complications like ischemia in orthopedic care.
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Which intervention is important in preventing pressure ulcers in immobilized patients?
- A. Frequent repositioning
- B. Encouraging immobility
- C. Maintaining prolonged periods of immobility
- D. Applying tight dressings over bony prominences
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers in immobilized patients by relieving pressure on skin over bones, boosting circulation, and reducing tissue breakdown risk. Sustaining or promoting immobility heightens this risk, as does tight dressings that add pressure and impair blood flow. Nurses implement this intervention shifting positions every two hours, for instance to protect skin integrity, a fundamental strategy in caring for those unable to move independently, prioritizing prevention over reactive treatment.
What best describes nurses as a care provider?
- A. Determine client's need
- B. Provide direct nursing care
- C. Help client recognize and cope with stressful psychological situation
- D. Works in combined effort with all those involved in patient's care
Correct Answer: A
Rationale: As care providers, nurses first assess client needs e.g., identifying respiratory distress before delivering care. This foundational step ensures interventions (like oxygen therapy) are targeted and effective, unlike direct care (an outcome), psychological support (a subset), or collaboration (a method). Accurate need determination, rooted in the nursing process, is the bedrock of care provision, guiding all subsequent actions in clinical practice.
Which assessment finding indicates a potential complication of immobility related to the respiratory system?
- A. Increased muscle strength
- B. Increased lung expansion
- C. Diminished breath sounds
- D. Normal respiratory rate
Correct Answer: C
Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.
The client has an allergy with penicillin. What is the best way to communicate this information?
- A. Place an allergy alert in the Kardex
- B. Notify the attending physician
- C. Write it on the patient's chart
- D. Take note when giving medications
Correct Answer: A
Rationale: Placing an allergy alert in the Kardex (A) is best; it's immediately accessible to all staff, per safety protocols. Notifying the physician (B) or charting (C) delays visibility, noting mentally (D) risks errors. A ensures quick action, making it correct.
The nurse and doctor jointly planned Mr. Gary's treatment. This is an example of?
- A. Collaboration
- B. Professionalism
- C. Health literacy
- D. Care transition
Correct Answer: A
Rationale: Joint planning with doctor is collaboration (A) working together, per definition. Professionalism (B) standards, literacy (C) understanding, transition (D) moves not joint-specific. A fits teamwork, making it correct.