Nokea
The nurse is caring for a client with a fractured pelvis in pelvic traction. Which activity is contraindicated?
- A. Log rolling to change positions.
- B. Deep breathing exercises.
- C. Using a trapeze for repositioning.
- D. Applying moisturizer to the skin.
Correct Answer: A
Rationale: Log rolling is contraindicated in pelvic traction to maintain alignment and prevent displacement.
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A client is scheduled for an ileostomy. Which of the following interventions would be most helpful in preparing the client psychologically for the surgery?
- A. Include family members in preoperative teaching sessions.
- B. Encourage the client to ask questions about managing an ileostomy.
- C. Provide a brief, thorough explanation of all preoperative and postoperative procedures.
- D. Invite a member of the ostomy association to visit the client.
Correct Answer: B
Rationale: Encouraging the client to ask questions about managing an ileostomy promotes active engagement, addresses specific concerns, and supports psychological preparation. Including family, providing explanations, or arranging visits are helpful but less directly empower the client's coping process. CN: Psychosocial adaptation; CL: Synthesize
On the second day following an abdominal perineal resection, the nurse notes that the wound edges aren't approximated and one half the incision has torn apart. The nurse should immediately take what action?
- A. Flush the wound with sterile water.
- B. Apply an abdominal binder.
- C. Cover the wound with a sterile dressing moistened with normal saline.
- D. Apply strips of tape.
Correct Answer: C
Rationale: Covering the wound with a sterile dressing moistened with normal saline protects the open wound from infection and keeps it moist until further medical evaluation. Flushing, applying a binder, or using tape are inappropriate without addressing the dehiscence first. CN: Physiological adaptation; CL: Synthesize
An older adult client in stage 2 of Parkinson's disease is being discharged with cellulitis of the right lower extremity. Which of the following nursing diagnoses will guide the discharge teaching? Select all that apply.
- A. Ineffective tissue perfusion related to decreased cardiac output.
- B. Impaired skin integrity related to barrier changes of the skin.
- C. Risk for injury related to environmental hazards.
- D. Impaired verbal communication related to dysarthria.
- E. Security intolerance related to painful lower extremity.
Correct Answer: B,C
Rationale: Cellulitis causes impaired skin integrity due to infection and inflammation. Parkinson's increases fall risk, supporting risk for injury. Other options are less directly related.
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
- A. Back at the level of the client's scapula.
- B. Back and head that are high.
- C. Seat that is lower than normal.
- D. Seat with firm cushions.
- E. Chair controlled by client's breath.
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.
After a bilateral adrenalectomy for Cushing's disease, the client will receive periodic testosterone injections. The expected outcome of these injections is:
- A. Balanced reproductive cycle.
- B. Maintained fluid and electrolyte balance.
- C. Stimulated protein metabolism.
- D. Stabilized mood swings.
Correct Answer: C
Rationale: Testosterone injections post-adrenalectomy stimulate protein metabolism, supporting tissue repair and muscle maintenance.