Nokea
The nurse is caring for a client with a fractured femur in traction.
- A. What is the most appropriate action for the nurse if the client reports numbness in the affected leg?
- B. Reposition the traction weights.
- C. Check the pin sites for infection.
- D. Assess the neurovascular status of the leg.
- E. Administer pain medication as ordered.
Correct Answer: C
Rationale: Numbness in the affected leg suggests possible neurovascular compromise, requiring immediate assessment of circulation, sensation, and motor function. Adjusting traction, checking pin sites, or giving pain medication does not address the urgent need to evaluate neurovascular status.
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Which of the following provides the best evidence that the nursing interventions to deal with a client’s self-care deficit in relation to feeding have been effective?
- A. The client eats at least one-half of all meals and drinks a minimum of 2,000 mL/day.
- B. The client’s dentures have been replaced, and he is able to chew.
- C. The client will eat without verbalizing suspicions when a particular nurse sits with him.
- D. The client appears to have increased energy to complete grooming activities.
Correct Answer: A
Rationale: Eating half of meals and drinking 2,000 mL/day is a concrete measure of adequate nutrition, indicating effective interventions. Options B, C, and D are less direct: dentures aid chewing but don’t ensure intake, suspicions suggest unresolved issues, and grooming energy is unrelated.
The nurse is teaching a client with a new diagnosis of epilepsy about valproic acid (Depakote). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any bruising or bleeding.
- C. Stop the medication if seizures decrease.
- D. Avoid regular liver function Test s.
Correct Answer: B
Rationale: Valproic acid can cause thrombocytopenia; reporting bruising or bleeding is critical. Options A, C, and D are incorrect or unsafe.
A client after right cataract surgery.
The nurse would intervene in which of the following situations?
- A. Client is in the supine position.
- B. The head of the bed is elevated 30°.
- C. The client is lying on her right side.
- D. An eye shield is over the right eye.
Correct Answer: C
Rationale: Strategy: 'Nurse would intervene' indicates an incorrect action. (1) appropriate position (2) decreases swelling and pain (3) correct-client should not be positioned with operative side in a dependent position or against the bed (4) shield is appropriate
A client with suspected Addison's disease is scheduled for a rapid corticotrophin stimulation test. Which of the following will the nurse include in her teaching?
- A. The need to limit fluid intake
- B. The need for periodic blood samples
- C. The need for collection of a 24-hour urine
- D. The need for frequent IV injections
Correct Answer: B
Rationale: The rapid corticotrophin stimulation test requires periodic blood samples to measure cortisol levels before and after ACTH administration.
A laboring woman who has dystocia is receiving oxytocin. The nurse observes a contraction lasting 90 seconds. What should the nurse do first?
- A. Slow down the rate of the oxytocin
- B. Turn the woman on her left side
- C. Give the woman oxygen
- D. Stop the oxytocin
Correct Answer: D
Rationale: Contractions longer than 60-90 seconds risk fetal hypoxia; stopping oxytocin immediately reduces uterine stimulation, prioritizing fetal safety.