Nokea
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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A nurse provides care to clients of a community clinic that serves a large immigrant population. Which intervention reflects primary prevention for this group?
- A. Screening for tuberculosis
- B. Providing vaccinations
- C. Referring clients with hypertension to a specialist
- D. Teaching clients with diabetes foot care
Correct Answer: B
Rationale: Primary prevention stops illness before it starts, vital for immigrants facing unique risks. Providing vaccinations like measles or flu shots builds immunity, preventing outbreaks in a group often under-vaccinated due to access or prior country norms, a top nursing action in clinics. Screening for tuberculosis is secondary, catching disease early, common in immigrant health but not preventive. Referring hypertension cases or teaching diabetic foot care is tertiary, managing existing conditions, not averting onset. Vaccinations align with primary prevention's proactive stance data shows they cut infectious disease rates in such populations addressing environmental and social vulnerabilities. Nursing leverages this to protect community health, ensuring immigrants, often in crowded settings, dodge preventable illnesses, a practical, impactful step for this clinic's focus.
Mr. Gary lost his job and feels overwhelmed. This is an example of?
- A. Crisis
- B. Illness
- C. Disability
- D. Stress
Correct Answer: A
Rationale: Job loss feeling overwhelming is a crisis (A) sudden disruption, per definition. Illness (B) is disease, disability (C) loss, stress (D) response not event-specific. A fits acute imbalance, making it correct.
A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?
- A. Call the physician
- B. Remedicate the patient
- C. Observe the emesis
- D. Explain to the patient that she can do nothing to help him
Correct Answer: C
Rationale: Observing the emesis checks for medication remnants, guiding next steps.
Mr. Gary died yesterday, His wife is not talking to anyone and prefers to be alone staring blankly at her husband's picture. This is an example of?
- A. Denial
- B. Anger
- C. Bargaining
- D. Depression
Correct Answer: D
Rationale: Not talking, staring blankly post-death is depression (D), per Kubler-Ross withdrawal, sadness dominate. Denial (A) disputes, anger (B) lashes, bargaining (C) negotiates all absent. Depression fits her isolation, making it correct.
What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
- A. Use sterile gloves when obtaining urine.
- B. Open the drainage bag and pour out the urine.
- C. Disconnect the catheter from the tubing and get urine.
- D. Aspirate urine from the tubing port using a sterile syringe.
Correct Answer: D
Rationale: Aspirating urine from the tubing port with a sterile syringe is the appropriate action for obtaining a sterile urine specimen from an indwelling catheter. This maintains the closed system's integrity, minimizing infection risk by avoiding exposure to external contaminants. The port is designed for sterile sampling, ensuring the specimen reflects bladder contents accurately for testing. Using sterile gloves aids asepsis but isn't the complete action; it supports the procedure, not defines it. Opening the drainage bag introduces bacteria, risking contamination and infection. Disconnecting the catheter breaks the sterile circuit, increasing urinary tract infection likelihood contrary to best practice. Aspiration via the port, paired with aseptic technique, upholds infection control standards, ensuring patient safety and reliable diagnostic results, making it the optimal nursing action.