Nokea
The nurse is caring for a client with a fractured femur who is in skeletal traction. Which of the following actions is MOST important for the nurse to perform?
- A. Check the pin sites for signs of infection.
- B. Ensure the weights are hanging freely.
- C. Perform range-of-motion exercises on the affected leg.
- D. Reposition the client every 4 hours.
Correct Answer: B
Rationale: Ensuring weights hang freely maintains proper traction alignment, preventing complications like malunion. Checking pin sites (A) is important but secondary, ROM exercises (C) are contraindicated in traction, and repositioning (D) is limited to maintain traction.
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After a painful exacerbation of rheumatoid arthritis, a patient is to begin a walking and exercise program.
An appropriate outcome would be that the patient:
- A. Avoids exercising when there is some discomfort.
- B. Is pain free while engaging in the activity program.
- C. Walks and exercise even when the pain is severe.
- D. Exercise unless the discomfort becomes too great.
Correct Answer: D
Rationale: Exercising until discomfort becomes too great balances activity with joint protection, promoting safe participation.
The client is receiving chemotherapy for cancer. Which statement, if made by the client, would indicate that she has accepted the diagnosis and treatment?
- A. I hate getting that treatment.'
- B. The doctor isn't sure if I really have cancer.'
- C. I have a collection of pretty scarves that I am wearing a lot now.'
- D. I don't go anywhere except for my treatments because I look so weird.'
Correct Answer: C
Rationale: Wearing scarves suggests acceptance of chemotherapy-induced hair loss, indicating adaptation to treatment and diagnosis.
The nurse is caring for a newborn who has just been diagnosed with hypospadias. When discussing the defect with the parents, the nurse should communicate that
- A. Circumcision can be performed at any time
- B. Initial repair is delayed until 6-8 years of age
- C. Post-operative appearance will be normal
- D. Surgery will be performed in stages
Correct Answer: D
Rationale: Surgery will be performed in stages. Hypospadias correction is done in stages as soon as the infant can tolerate surgery.
A patient has been receiving a cardiac glycoside, a diuretic, and a vasodilator and is on bedrest. The patient's apical pulse rate is 44.
The nurse concludes that this pulse rate is most likely a result of the:
- A. Diuretic
- B. Vasodilator
- C. Bedrest regimen
- D. Cardiac glycoside
Correct Answer: D
Rationale: Cardiac glycosides like digoxin can cause bradycardia, especially at a pulse of 44.
When explaining the therapeutic regimen of vitamin B12 for pernicious anemia to a patient the nurse should explain that:
When explaining the therapeutic regimen of vitamin B12 for pernicious anemia to a patient the nurse should explain that:
- A. Weekly Z-track injections are required for control.
- B. Daily intramuscular injections are required for control.
- C. Intramuscular injections once a month will maintain control.
- D. Oral tablets of vitamin B12 taken daily will keep the symptoms under control.
Correct Answer: C
Rationale: Monthly B12 injections maintain control in pernicious anemia due to absorption deficits.