Nokea
The nurse is caring for a client with a fractured tibia placed in an external fixator. Which of the following should be included in the plan of care?
- A. Keeping the leg flat at all times
- B. Checking the pin sites for signs of infection
- C. Massaging the leg to promote circulation
- D. Ambulating the client within 12 hours of application
Correct Answer: B
Rationale: Checking pin sites for infection (redness, drainage) is critical in external fixator care for a fractured tibia, preventing osteomyelitis flat legs, massage, or early ambulation risk stability or healing. Nurses monitor this, ensuring site care and antibiotics if needed, supporting bone recovery.
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Considered as the most accessible and convenient method for temperature taking
- A. Oral
- B. Rectal
- C. Tympanic
- D. Axillary
Correct Answer: A
Rationale: Oral temperature is most accessible e.g., quick placement under tongue requiring minimal prep, unlike rectal (invasive), tympanic (equipment), or axillary (longer). Convenient for alert patients, it's standard in clinics, per nursing practice, balancing ease and reliability for routine monitoring.
The nurse ensured Mr. Gary's bed rails were up. This is an example of?
- A. Patient safety
- B. Collaboration
- C. Health promotion
- D. Nursing informatics
Correct Answer: A
Rationale: Ensuring bed rails up is patient safety (A) harm prevention, per definition. Collaboration (B) teams, promotion (C) well-being, informatics (D) tech not safety-specific. A fits protective action, making it correct.
After a month, Mr. Gary's wife started going to her old routine, She said 'Gary would want me to continue living my life' This is an example of what stage of grieving?
- A. Denial
- B. Anger
- C. Bargaining
- D. Acceptance
Correct Answer: D
Rationale: Resuming routine with 'Gary would want is acceptance (D), per Kubler-Ross peace with loss, moving forward. Denial (A), anger (B), and bargaining (C) resist or alter reality. Acceptance reflects her adjustment, making it correct.
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.
Which assessment finding indicates a potential musculoskeletal complication of immobility?
- A. Increased muscle tone
- B. Active range of motion (ROM)
- C. Contractures
- D. Strong and flexible joints
Correct Answer: C
Rationale: Contractures permanent muscle and tendon shortening indicate a musculoskeletal complication of immobility, restricting joint movement due to prolonged stillness. High muscle tone might suggest other conditions, while active motion and strong joints reflect health, not issues. Nurses assess for this to initiate stretching or therapy, countering the stiffening that immobility causes, ensuring musculoskeletal function is preserved as much as possible in affected patients.