Nokea
The nurse is caring for a client with a femoral fracture in traction. Which observation indicates a potential complication?
- A. Client reports mild discomfort.
- B. Traction ropes are aligned with the pulley.
- C. Foot is pale and cool to touch.
- D. Pin sites are clean and dry.
Correct Answer: C
Rationale: A pale, cool foot suggests impaired circulation, a serious complication requiring immediate attention.
You may also like to solve these questions
When the nurse enters the client's room, the nurse perceives that the client is staring straight ahead. Which of the following is the best course of action for the nurse to take next?
- A. Hold an interdisciplinary meeting on the client's behalf promptly.
- B. Consult with psychiatry.
- C. Listen to the client and observe the body language.
- D. Address the client by first name upon entering the room.
Correct Answer: C
Rationale: Listening to the client and observing body language allows the nurse to assess the client's condition and needs, considering macular degeneration may cause the client to appear to stare straight ahead due to central vision loss.
Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease?
- A. Encouraging regular ambulation.
- B. Promoting bowel rest.
- C. Maintaining current weight.
- D. Decreasing episodes of rectal bleeding.
Correct Answer: B
Rationale: Promoting bowel rest is the priority during a Crohn's exacerbation to reduce inflammation and symptoms. Ambulation, weight maintenance, and reducing bleeding are secondary to resting the bowel. CN: Physiological adaptation; CL: Synthesize
A client who is recovering from a subtotal gastrectomy experiences dumping syndrome. The client asks the nurse, 'When will I be able to eat three meals a day again like I used to?' Which of the following responses by the nurse is most appropriate?
- A. Eating six meals a day is time-consuming, isn't it?'
- B. You will have to eat six small meals a day for the rest of your life.'
- C. You will be able to tolerate three meals a day before you are discharged.'
- D. Most clients can resume their normal meal patterns in about 6 to 12 months.'
Correct Answer: D
Rationale: Most clients can gradually resume a normal meal pattern (three meals a day) within 6 to 12 months as the body adapts post-gastrectomy, making this the most accurate and supportive response.
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
- A. Speaking loudly.
- B. Using a picture board.
- C. Writing directions so client can read them.
- D. Speaking in short sentences.
Correct Answer: B
Rationale: A picture board is most helpful for expressive aphasia, allowing the client to point to images to communicate needs. Speaking loudly, writing directions, or short sentences are less effective for clients unable to verbalize.
A client is receiving Pentoxifylline (Trental) for intermittent claudication. The nurse should determine the effectiveness of the drug by asking the client:
- A. If he has improved circulation in the legs
- B. If he can wiggle his toes
- C. If he is urinating more frequently
- D. If he is less dizzy
Correct Answer: A
Rationale: Pentoxifylline improves blood flow by reducing blood viscosity and increasing erythrocyte flexibility, alleviating intermittent claudication. Asking about improved leg circulation (e.g., reduced pain or increased walking distance) assesses its effectiveness. Toe movement, urination, and dizziness are unrelated to its therapeutic action.