Nokea
The nurse is caring for a client with a closed reduction of the left forearm. Which finding should be reported to the physician immediately?
- A. The client complains of pain at the site of the fracture
- B. The client's fingers are cool and pale
- C. The client's cast has a foul odor
- D. The client's radial pulse is 88 beats per minute
Correct Answer: B
Rationale: Cool, pale fingers post-left forearm closed reduction indicate circulatory compromise, possibly compartment syndrome, needing urgent reporting pain is expected, odor suggests infection (less acute), and pulse (88) is normal. Nurses assess neurovascular status, acting fast, preventing tissue damage in this orthopedic emergency.
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Which of the following nursing intervention is appropriate to prevent pulmonary embolus in a patient who is prescribed bed rest?
- A. Limit the client's fluid intake
- B. Encourage deep breathing and coughing
- C. Use the knee gatch when the client is in bed
- D. Teach the patient to move legs in bed
Correct Answer: D
Rationale: Bed rest risks venous stasis, a pulmonary embolus cause. Leg movement promotes circulation, preventing clots from forming and traveling to lungs. Fluid limits dehydration but not emboli directly, deep breathing aids lungs but not veins, and knee gatch increases stasis. Nurses teach exercises, reducing thromboembolism risk, enhancing recovery safety.
The nurse checked if Mr. Gary's pain improved after medication. This is an example of?
- A. Evaluation
- B. Implementation
- C. Assessment
- D. Planning
Correct Answer: A
Rationale: Checking pain improvement is evaluation (A) assessing outcomes, per process. Implementation (B) delivers, assessment (C) gathers, planning (D) sets not outcome-specific. A fits goal review, making it correct.
Too narrow cuff will cause what change in the Client's BP?
- A. True high reading
- B. True low reading
- C. False high reading
- D. False low reading
Correct Answer: C
Rationale: A narrow cuff e.g., under-sized overcompresses, yielding a false high BP e.g., 140/90 vs. true 120/80. True readings need proper fit; wide cuffs may lower falsely. Nurses select cuffs e.g., per arm size for accuracy, per measurement standards.
They put girls clothes on male infants to drive evil forces away
- A. Chinese
- B. Egyptian
- C. Indian
- D. Babylonian
Correct Answer: A
Rationale: Ancient Chinese dressed male infants in girls' clothes to confuse demons e.g., during infancy rites believing males drew evil. Unlike Egyptian, Indian, or Babylonian customs, this reflects spiritual protection, offering insight into cultural health beliefs relevant to nursing's cultural competence.
What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?
- A. Measure intake and output
- B. Check albumin level
- C. Monitor glucose levels
- D. Increase enteral feeding
Correct Answer: A
Rationale: Monitoring I&O ensures fluid balance with hyperosmotic enteral feeding.